Welcome to the family health and wellness centre. Our focus is to provide the highest standard of treatment, care and ethics to best suit the needs of our family community.
Please take a few minutes to fill out the patient form before your first appointment. Once finished, press submit and the form will automatically be sent to our clinic before your arrival.
If you have any question regarding this, please feel free to contact us at 403-289-8285 or email to us at firstname.lastname@example.org.
Once again, welcome and thank you for choosing Century Chiropractic Wellness Centre.
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.
Consent to the Use and Disclosure of Health Information
I understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as a basis for planning my care and treatment; a means of communication among other health professionals who may contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; and a means by which a third-party payer (MVA, WCB) can verify that services billed were actually provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the practice is not required to agree to the restrictions requested.
I hereby agree that the information that I am providing is accurate to the best of my knowledge and I will not hold Century Chiropractic Wellness Centre, its staff, doctor(s), or other practitioner(s) responsible for any information that I have not provided to them during the initial involvement and/or treatment provided thereafter at Century Chiropractic Wellness Centre.
Thank you for taking the time to fill out our forms. Your information is private and confidential. It will go a long way to helping us to help you to achieve your health goals. We look forward to meeting you!
To the best of your knowledge, please ensure that the information provided is accurate (click "Agree" below)
* Please read and agree to the terms
Today's Date: 16 Jul 2019