Patient Information & Disclaimer Form
Complete your details and health history before your appointment so Dr George can review and discuss suitable options with you.
Full Name
*
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Email Address
*
example@example.com
Which treatment are you interested in?
*
Chiropractic
Acupuncture
Vitamin injection
Aesthetics
Not sure yet
Please list any health conditions, previous injuries or operations, allergies, or previous reactions to treatment George should know about.
Are you currently taking any medication or supplements?
Are you currently pregnant, possibly pregnant, or breastfeeding?
Yes
No
Not applicable
Prefer to discuss privately
Is there anything else George should know?
I confirm that the above information is accurate to the best of my knowledge, I will inform Dr George if anything changes, and I understand I can ask questions and decide whether or not to proceed with any proposed treatment.
*
I agree
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: