History of Complaint
Please identify the complaints that have brought you to our office (Please describe in detail):
On the scale of 0 to 10, with 10 being the worst pain, rate your above complaints:
OPT-IN CONSENT FOR E-MAIL
The email I would like to have on file is a personal, non-shared, confidential email. I assure Vida Chiropractic that information sent to this email is secure and does not place Vida Chiropractic at risk of breaching confidentiality or privacy regulations.
The Statements made on this form are true to the best of my knowledge and I consent to allow Vida Chiropractic to further evaluate my condition with an exam and other tests as deemed necessary by the doctors.