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Contact Us
Home
About Us
Our Team
Facilities and Services
Fees
Success Stories
Workshops
NutriDyn Nutritional Support
Affiliates
Chiropractic
Chiropractic
New Patients
Innate Wellness
Massage
Fitness
Innate Wellness
Functional Fitness
Special Offers
Contact Us
PROGRESS REVIEW FORM 5
Name
*
First Name
Last Name
Review Consent
*
I hereby give consent to undergo a chiropractic review, evaluation and/or posture image.
1. Would you consider writing us a review?
2. What are your current health goals?
3. How do you find your regular adjustments help you?
4. On a scale of 1-being poor, to 10-being brilliant, please rate yourself on the following:
Energy
1
2
3
4
5
6
7
8
9
10
Sleep
1
2
3
4
5
6
7
8
9
10
Nutrition
1
2
3
4
5
6
7
8
9
10
Exercise
1
2
3
4
5
6
7
8
9
10
5. How many times a week do you perform any spinal mobility exercises?
6. How much water do you drink per day?
7. Do you have any questions or concerns you wish us to address?
8. Do you take any supplements or have any questions about this?
9. Would you like any additional information on our Massage, 8WW, Functional Fitness, Supplements or Health Workshops?
10. Is there anyone you would like a New Patient voucher for?
I am happy for my feedback and pictures to be used in office, on our social media, and/or website
*
Yes
No
On-going Consent
*
A Chiropractic adjustment is considered to be a safe and effective form of therapy for spinal conditions, i.e. vertebral subluxation. A re-evaluation has been performed. If you have any questions about this, please ask your chiropractor.
I have read the above statement and therefore consent to ongoing spinal adjustive Chiropractic treatment.
Date
*
MM
DD
YYYY
Thank you!
