Welcome to our online Patient Application Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories sign the consent (you can use your mouse or touch screen) and then click the [Submit] button on the last page on the bottom right.
Select options below indicating age at diagnosis and other relevant details.
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?
How do you want us to handle your problem?
Please read the following carefully before signing.
I have completed my health questionnaire to the best of my knowledge and ability. I understand that completing this application is part the beginning of my journey to better health. I understand that my first visit will require 30 to 45 minutes and will consist of a review of my health history I have provided, a consultation, a complete chiropractic neurological examination, including: posture analysis, ranges of motion, palpation, Insight Millennium scans (surface electromyography, inferred thermography),to determine the current level of function of my nervous system, and any necessary x-rays will be requested (to rule out pathology, to determine the current structure of my spine and if there is any degeneration). X-rays will be taken at a convenient off-site location and with current Alberta health care, are at no cost. I understand that all the information gathered by Atlas Family Chiropractic is strictly confidential. Personal information will not be released to any other party without the appropriate authorization from you. My history and evaluation will help determine if there is any damage in my spine, if there is any nerve interference and if neurological corrective chiropractic care will benefit my current health condition and/or to my overall health and wellness.
* Please read and agree to the terms
Today's Date: 23 Jan 2019