ACCEPTANCE AS PATIENT

I understand and agree that Dr. David DeFries D.C. has the right to refuse to accept me as a patient any time before treatment begins. The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process of information gathering so that the doctor can determine whether to accept me as a patient.

By clicking next, I agree with the above statement and wish to continue with providing my information.

As you go through the form, some questions will require short answers. For example, questions about your medical history or specific symptoms may require brief responses. If you are using a phone or tablet, you can click the microphone icon and speak your answers or type them using the keyboard.

Questions that allow for multiple answers (e.g., describing the pain) will contain squares next to the answers, while single-answer questions (e.g., where does it hurt) will have circles.

Next will be a series of symptoms. If you currently are experiencing these or have in the past, please select Yes or choose No if they do not apply.