Synaptic Chiropractic Center

Patient Intake Form

**IMPORTANT** Under the section "REASON FOR VISIT", on the 3rd page of this form; if your symptoms are related to an AUTO INJURY or WORK INJURY, please select the corresponding item from the drop-down menu when asked. This will allow us to collect the necessary information for the insurance company. If you are unsure of the "REASON FOR VISIT", please select the "PAIN" option from this drop-down.

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