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Online Forms

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Kenneth Clare D.C. offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form – Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Step 1 of 3

Patient Data

Name(Required)
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* Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions

Mailing Address

Address(Required)
MM slash DD slash YYYY

Current Complaints

Nature of Injury
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Have you ever had same condition?
MM slash DD slash YYYY
Have you ever been under chiropractic care?

Insurance Information

Do you have health insurance?
* If an auto accident, please provide:

Signatures

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.
MM slash DD slash YYYY
MM slash DD slash YYYY

Download the free Adobereader®. CLICK HERE

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