Synergy Chiropractic

Patient Intake Form

PLEASE NOTE: Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. Please be sure to answer ALL QUESTIONS and leaving no blank answers. Blank answers will need to be answered in office and will delay your start time with the doctor. Enter your MAIN complaint ONLY on the first page and additional complaints can be added after completion of the main complaint area. AUTO ACCIDENTS/WORKERS COMPENSATION CASES PLEASE CHECK YES FOR PERSONAL INJURY.

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