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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!

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Patient Data

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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

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Current Complaints

Nature of Injury
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Have you ever had same condition?
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Have you ever been under chiropractic care?

Insurance Information

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


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.
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Download the free Adobereader®. CLICK HERE

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