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In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Hope for Healing

No matter what level of pain you are experiencing, Dr. Jackson wants you to know that no issue is too big and that you can find relief. Many of his patients come to him with complex or chronic issues. When patients make a commitment to their health and overall well-being, Dr. Jackson is able to help them overcome spinal issues they thought they would have to live with forever.

You won’t get a prescription and head home as you might elsewhere, and life-changing results don’t necessarily happen overnight. Chiropractic can do amazing things for people. Many of our patients have overcome debilitating conditions and found a level of well-being they never imagined.

THIS ---->https://shawchiropracticcocom.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday7 - 11:301:30 - 5:30
Tuesday7 - 11:301:30 - 5:30
Wednesday7 - 11:301:30 - 5:30
ThursdayClosed
Friday7 - 12:00
SaturdayClosed
SundayClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7 - 11:30 7 - 11:30 7 - 11:30 Closed 7 - 12:00 Closed Closed
1:30 - 5:30 1:30 - 5:30 1:30 - 5:30

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