Back Doctor Chiropractic History Form

New Patient Form
Welcome to Back Doctor Chiropractic Clinic!

We are delighted that you have chosen Back Doctor Chiropractic to begin your journey to better health. Before you come to see one of our chiropractors we ask that you take some time to fully complete this questionnaire so that we more fully understand your health needs. If you have any questions or require further help please contact the clinic on 01745 535854 or admin@back-doctor.co.uk

Please read the following concerning the possible risks and side effects of chiropractic treatment.

It is common for patients to feel sore after treatment for one or two days.

There are rare cases of sprains/strains following treatment.

Adjustments in the rib region have been known to cause rib fracture/dislocation. This is an extremely uncommon occurrence.

There have been rare reports of cervical or lumbar disc damage following an adjustment, but there is no evidence that it was caused by the adjustment.
I have considered the risks of treatment, especially in relation to COVID 19 transmission and I consent to examination and treatment *

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Date *

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Date
I am happy to receive communications from the clinic *

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I am happy for you to contact my GP or insurance company. I understand that you will not do this before asking me again verbally. *

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