Website New Patient Registration Form, Insurance, Consent, Scheduler

New Patient Registration

Please fill in the form below
Name *

First Name Middle Name Last Name
E-mail
Sex
Date of Birth *

Month Day Year
Contact Number: *

Area Code Phone Number
Marital Status
Mailing Address: *

Street Address

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City State / Province

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Taking any medications, currently?

Yes No
If yes, please list it here
List the area(s) that are bothering you today?
Scale of 1-10 what is your pain level today. 10 being the worst pain of your life?
Informed Consent

I will use my hands or a mechanical instrument upon your body in such a way as to move your joints. This procedure is referred to as ”Spinal Manipulation” or Spinal Adjustment” As the joints in your spine are moved, you may experience a “pop” as part of the process.I will use my hands or a mechanical instrument upon your body in such a way as to treat the affected muscles groups. There are certain complications that can occur as a result of a spinal manipulation. These compilations include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, fractures, strains and dislocations, Bernard-Horner’sSyndrome (also known as oculosympathethetic palsy), costovertebral strains and separation. Rare complications include, but are not limited to stroke. The mos common complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment. I am aware of these complications, and in order to minimize their occurrence I will take precautions. These precautions include, but are not limited to my taking a detailed clinical history of you and examining you for any defect which would cause a complication. This examination may include the use of x-rays. The use of x-ray equipment may pose a risk if you are pregnant. If you are pregnant,you should tell me when I take you clinical history.
I have read the above and agree to receive treatment From Dr. Dominique Taylor *

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Please Type Your Full Name as Signature *
Date *

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Date
Schedule an Appointment / Or Confirm Current Scheduled Appointment

If scheduling for the first time you will receive a confirmation call from our office for this appointment.
Date

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Date
Time

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New Patient Registration

Informed Consent

Schedule an Appointment / Or Confirm Current Scheduled Appointment