Free Phone or TeleHealth Consultation Request Form

Free Consult: Confidential Patient Information

Please fill in the form below
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
E-mail:
Birth Date

MonthDayYear
Sex:

MaleFemale
Marital Status:
Primary Care Physician MD name:*
Your primary MD's Phone Number:*

Area CodePhone Number
We may need to contact your MD for records and to update them on your care here. We need your permission to do this.*

YESNO
Have you seen a chiropractor or nutritionist in the past?*

YesNo
If you have seen a chiropractor or nutritionist what worked best for you when you were under their care?
how did this holistic or natural care help you?
Was there anything that this healthcare professional or office staff did that you disliked?
What other chiro did that I did not care for
Person who referred you or how did you find out about our office:*
If referred by a friend or doctor, who can we thank for recommending that you come see us? Full name if you know it. (If no one referred you just say "no one")*
referrer's name or write n/a
Work Information
Employer:

employer nameyour position there
activities at your job
sitting, standing, computer work, lifting, etc.
Spouse Information/Policy Holder
Full Name:

First NameLast Name
Birth Date:

MonthDayYear
Occupation:
In case of Emergency
Contact:

First NameLast Name
Phone Number:

Area CodePhone Number
Relationship:
I understand and agree to authorize the doctors at Life Enhancing Wellness Centers, LLC and/or the properly trained staff to administer examination procedures and treatments, as deemed necessary at that time:
Signature

Clear
Date:

MonthDayYearHourMinutesAM/PM Option

Free Consult: Confidential Patient Information

Work Information

Spouse Information/Policy Holder

In case of Emergency