Please provide the following
Cell Phone #
Zip/Postal Code/Country E-mail
Address NOTE: Legault Chiropractic does NOT sell
nor share your e-mail address with Any outside parties, except as You request.
We may send you an E-Newsletter once a month &/or a notice of any
"Specials of the Month" as they may interest
Local Street Address (if different) Local
Place of Employment Social Security #
Name of Spouse
Name of Children &
WHOM may we be Thank for
Referring You to our office?
Have you EVER had Chiropractic
Care in the Past ?
If "YES" Please indicate When?
Name of your prior
and Why did you stop?
Was it a Great
Did they take Spinal X-rays?
I can not recall
Approx date of Last Spinal X-rays
HOW CAN WE SERVE YOU?
What is you reason for
seeking Chiropractic care
I have no complaints. I am here for a wellness check up.
I am seeking Chiropractic care for the following -
Is this related to: Personal Health Problem(s) Work Accident Auto Accident School/Sports Injury
SUBLUXATIONS (spinal misalignments) interfere with the
communication from your brain to your body. When these interferences are
advanced, an alarm system occasionally signals for help by sending signs or
symptoms such as pain, numbness &/or health problems to let you know that
there is a problem. Please let us know where the alarm system is sounding on
Neck Pain Headaches Shoulder/Arm/Hand Pain Allergies
Mid Back Pain Dizziness Hip/Leg/foot Pain Sinus Problems
Low Back Pain Nervousness Digestive Problems Loss of Sleep
Constipation Numbness/Tingling Difficulty Breathing Urinary Problems
(Females only: Are You Pregnant?
Do you/Did you have Menstrual Problems
Signs of Menopause
did these signs or symptoms that brought you here 1st appear?
Are these signs or symptoms:
A Subluxation irritates
nerves with various sensations. Is yours? (Select Any /All of
the following options that apply):
Sharp Burning Throbbing Stabbing Dull Achy
SOCIAL HABITS: Do you Exercise
a healthy diet
1 or Less
of glasses per day Tobacco/Smoke
Less than 1
PAST HISTORY: Have you EVER had any SURGERY:
Select any/ALL of the following options that apply:
Tonsils Appendix Gall Bladder Heart Cancer Spinal Surgery
Other I have NEVER had Any Surgeries
(Females Only:Caesarian Hysterectomy Other
Please LIST ALL
MEDICATIONS for ANY Health Problem(s)
REVIEW OF BODY SYSTEMS:
(Examples Only, Your Problem(s) may be Different) Please “CHECK OFF Any/ALL
System which gives you a problem or for which you are taking medications.
HEART/CIRCULATION (Bld. Pressure) LUNGS/RESPIRATORY (Asthma) GASTROINTESTINAL (Heartburn/Constip./Diarrhea)
BLOOD/LYMPHATIC (Leukemia/HIV Pos.) NEUROLOGICAL (Numbness/paralysis) ENDOCRINE/HORMONES (Diabetes/Thyroid/Female Hormones)
EYES (Glasses/Glaucoma/ Other) IMMUNE SYSTEM (Freq. Colds/Fever) SKIN (Rashes/Pimples/Skin Cancer)
EARS/NOSE/THROAT/MOUTH GENITO/URINARY (Reproductive/Bladder) PSYCHIATRIC (Depression / Extreme Stress)
PERSON/ENTITY RESPONSIBLE FOR THIS
SELF + SPOUSE / GUARDIAN
SELF + INSURANCE
NOTE: It is the Patient's Responsibility to Notify the Legault
Chiropractic Health Center Who is Liable for Charges
incurred &/or to be incurred in this Office & Re-Notify Immediately if
their "Care Liability" CHANGES while under care. [ex. from-to:
Personal / Auto Accident / Workers' Comp / Other]
PRIVACY STATEMENT: We, at the Legault Chiropractic Health Center ,
honor and respect all of our patients & their right to privacy. It is the
regular policy of this office to minimize disclosure or dissemination of any
personal information on any/all of our patients. Neither your name, address,
phone number(s) nor health/financial record will be used, nor shared with any
outside agent, except as expressed & authorized by you (example – your
spouse &/or Insurance Company) or as Required by Law.
FEES ARE DUE WHEN SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS
HAVE BEEN MADE.
[A copy of your driver’s license is mandatory if payments
are to be Other than CASH.]
I hereby authorize the Legault Chiropractic Health Center to
disclose my private health and financial information to &/or
(ex: Name your Spouse/Parent/Adult-Child /Insurance Company) for the
purpose of payment, coordination of my care &/or to transport said
information for me in my absence.
Signature of Patient
Patient's Authorization for Care
By signing below I authorize the Legault Chiropractic Center to
evaluate and treat me, my minor, or my legal dependant.
I consent to be evaluated and receive chiropractic care
SIGNATURE: Date mm/dd/yy
I understand that if I Sign &/or Send this Form
Electronically, that my Electronic Signature is the SAME as a Hand Written
Signature. [Electronic Transmission NOT Available at
To PRINT Click 'CTRL' + 'P' at same time
Please NOTE: At this time, this form can NOT be
Transmitted Electronically. Therefore, PLEASE PRINT this FORM, SIGN it where indicated, & BRING IT with YOU when you COME IN for your
Being in PAIN is Not Fun! Help Us to Help
Others! Don't wait! Tell your Family &
Friends about this Website.
You may be the one who Saves them from a Great Deal of Pain/Suffering or
maybe even SAVES their LIFE !
What a GREAT FEELING that can be for YOU!
Policy -Privacy Practice] [Conctactenos]