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Revelation Chiropractic
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  • About Us
  • Your First Visit
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    • New Patient Form
    • Reactivation Patient Paperwork
    • Auto Injury Patient Intake
    • Patient Progress Evaluation
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Reactivation Patient Paperwork

Reactivation Patient Paperwork Form

  • REACTIVATION PATIENT PAPERWORK

  • Date Format: MM slash DD slash YYYY
  • (Or guardian's cell if patient is a minor)
  • (Or guardian's email if patient is a minor) *Required because we will email all your scans and evaluation results to you after your initial reactivation appointment.*
  • (For children, enter parent/guardian's email above)
  • (For minors who do not have an occupation, put "child")
  • PURPOSE OF THIS VISIT

  • Date Format: MM slash DD slash YYYY
  • (Check only if your reason above is for general health/wellness care/etc.)
  • Date Format: MM slash DD slash YYYY
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • SYMPTOMS QUESTIONNAIRE

  • This section is focused on misalignment of the neck region.
  • This section is focused on misalignment of the mid-back region.
  • This section is focused on misalignment of the low back region.
  • This section is focused on misalignment of the pelvis.
  • EXPERIENCE WITH CHIROPRACTIC CARE

  • Date Format: MM slash DD slash YYYY
  • HEALTH LIFESTYLE

  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • HEALTH INSURANCE

  • Date Format: MM slash DD slash YYYY
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