• STEMWAVE New Patient Form

  • Personal Information

  • Date of Birth
     / /
  • Gender
  • Sex
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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  • Current Health Concern

  • Type a question
  • Any Secondary Health Concerns?
  • How long have you had this concern?
  • Have you seen a physician or other health practitioner about this?
  • How would you describe your general state of health?

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  • Cardiovascular
  • Please check the boxes for any condition(s) you have experienced or are experiencing:

  • Bone Health
  • History of Fractures?

  • Arthritis
  • Have you been diagnosed with arthritis at the area of complaint?

  • Diabetes
  • Do you have Diabetes?
  • Do you have cancer/tumor?
  • Are you on NSAIDS, Opioids or anti-coagulant treatment?
  • Have you received a cortisone injection within the last 30 days?
  • If yes, date
     / /
  • Are you currently pregnant?
  • If yes, when is your due date
     / /

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  • RISKS OF TREATMENT: There may be temporary pain 7/or soreness. This typically resolves within hours or 1-2 days. CONSENT TO TREAT: I hereby consent to authorize the application of Stemwave treatment for the above stated issues on myself or child. I fully understand the nature of Stemwave treatment because I have researched the treatment option &/or the treatment has been fully explained to me by the the treating chiropractor/staff. I confirm that upon entering the facility I have been provided the opportunity to have a discussion to clarify any concerns I may have for myself or my child. I authorize that guaranteed results/expectations have not been promised to me. I also understand I am foregoing the opportunity for alternative &/or medical treatments and opting to have Stemwave treatments per my personal discretion.

  • Date
     / /

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  • In our office, a credit card is required to have on file. If you were to miss your/your child's Stemwave appointment without notifying the office or rescheduling, there will be a $100 fee.

  • Expiration date
     / /

  • Your signature indicates you have read and are aware of our no-call/no-show policy.

    We look forward to serving you in our office!

  • Date
     / /

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