Confidential New Patient Form

This form is for new patients and reassessment appointments.

An appointment at the clinic must be booked before completing this form.

On completion, a copy of this form will be sent to you.

First name

Last name

Date Of Birth

Contact Number

Occupation

GP Practice

Home Address + Post Code

If you have health insurance, who is it with?

In your own words, please describe the issue you would like assessed:

How long have you had this issue?

How do you think the issue started?

Is there anything that makes the issue worse?

Is there anything that makes the issue ease?

Are there any other symptoms that concern you or you would like to discuss?

Please confirm if you currently suffer from, or have suffered from in the past, any of the following:

If you answered 'YES' to any of the above, please give some detail:

Please list all medications/vitamins/supplements you take:

Please list any surgeries or accidents that have taken you to hospital and when they occurred

Could you be pregnant?

Yes

Do you smoke or vape?

Yes

Do you drink alcohol?

Yes

By signing below you confirm that you have read and understood the following:

Your consultation will consist of a discussion concerning general medical information and specific information regarding your presenting complaint. The examination will include Orthopaedic, Neurological and Chiropractic testing to allow a diagnosis to be formulated. On completion of the examination, your Chiropractor will discuss the relevant findings with you. This will include a working diagnosis, a treatment plan and an explanation of the type of treatment recommended.

If treatment is indicated, we will begin with your verbal consent. The consent for treatment can be withdrawn by you at any time and we encourage you to ask as many questions as you see necessary to understand your condition and the treatment we propose.

Chiropractic, like any physical therapy, is NOT guaranteed and there is a small risk of adverse reaction following treatment. The most common is an increase in your presenting symptoms, which usually subside within 24/48 hours. A theoretical link between Cervical manipulation and stroke has been suggested, although the risk can never be entirely ruled out, current research suggests this risk is less than 1 in 1 million neck manipulations. Research has shown Chiropractic to be one of the safest and effective forms of treatment for a number of musculoskeletal issues.

I understand that Falkirk Chiropractic Clinic requires 24 hours notice to reschedule or cancel an appointment. I understand that if I cancel or reschedule my appointment within 24 hours (or fail to attend my appointment) a missed appointment fee may be payable.

I have read and understand the above statement and I hereby give my consent to a physical examination and chiropractic treatment. I understand that this consent can be withdrawn at any time:

Yes

Under the General Data Protection Regulations (GDPR 2018) we are required to make you aware of our Data Protection Policy. A paper copy is available on request and via our websites Privacy Policy

I give my consent for the clinic to securely store my data on our system and as a hard copy if required:

Yes

I give my consent to be contacted by phone/text/email for appointment communication/confirmation of appointments and/or if I fail to attend an appointment.

Yes

I give my consent for the clinic to contact my GP or other healthcare professional in case of emergency or if clinically indicated:

Yes

Please tick below if you would like us to stay in touch with you about any clinic updates. We will never sell or share your information onto a 3rd party and you can withdraw consent at any time:

Yes

Your Signature

Date

Thanks for submitting your new patient form. You will receive a confirmation email which confirms that we have received your form.

If you have any questions, please do not hesitate to contact the clinic.

Confidential New Patient Form

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