Dr. Touraj Najafian, Dr. Mark Halpern & Dr. Lauren Stethem

2300 Yonge St. Suite 2004

Toronto, ON M4P IE4

How would you rate your stress level? (0 = no stress, 10 = severe)?

Please check all the symptoms you have ever had under each category, even if they do not seem related to your current problem. Your Doctor will then be able to recommend what type of care you need to achieve balance.

Your time is valuable. We do our best to prepare our day to be prompt and we ask that you do the same. You can help us remain on time by calling or emailing ahead if you need extra time to get here due to unforeseen circumstances. We ask that if you must cancel us it possible or to reschedule give your an time appointment, patient. please give You will 12hrs be charged notice. This your courtesy appointment makesto another fee if you miss an appointment, or don't notify us of a cancellation or reschedule before your allotted time. We will consider circumstances before charging a fee. We appreciate your understanding and cooperation.

Do you have extended health coverage? Most insurance companies cover Chiropractic Services and can help pay for some of your care.

(Some Insurance Companies require a M.D's note for Orthotics. Please review your policy)

IF YOU DONT KNOW THE ANSWERS TO THESE QUESTIONS, PLEASE MAKE SURE YOU TAKE THIS FORM HOME AND RETURN IT COMPLETED AT YOUR NEXT VISIT WHEN YOUR CARE WILL BE DISCUSSED.

Thank you for your co-operation!