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Tooting New Client Online Assessment - 1

Personal Information

Our practice is designed to help you achieve optimal health and vitality.

Please take your time to fill in the following information in detail. This 6 page assessment generally takes 10 to 15 minutes to complete.

Mobile users may find the experience difficult so we suggest using alternative means.

Completing this ensures we have all the information we require prior to you attending to assess, evaluate and care for you properly.
Some questions may seem slightly odd but they are important to help assess your overall health and well being.

Unfortunately in the event your assessment isn't completed prior to attendance It is unlikely we will be able to care for you properly and you will be asked to reschedule your appointment.

If you experience any difficulties completing this, please do not hesitate to get in touch on 02087676718.
Name *This question is required.
This question requires a valid date format of DD/MM/YYYY.
calendar
Address? *This question is required.
Contact Details *This question is required.
Marital status
Children's names and ages?
How did you find us? *This question is required.
Do you have health insurance that may cover some of the cost of chiropractic care? *This question is required.
Is your provider: *This question is required.
Please be advised that Tooting Chiropractic does not accept insurance based referrals from, HCML or BUPA. 

You are still welcome to see us at your own expense, however, you will not be able to claim for this. 

Please do not ask us to change this non negotiable policy as refusal may offend. We also accept no responsibility in the event that this notice is overlooked.

If insurance is a must, we would recommend cancelling your appointment and visiting Putney Chiropractic instead (02087856144)
 
Please be advised that we do not invoice insurers directly. 

All accounts must be settled on the day of consultation and we will gladly issue you a receipt so you may claim back any entitlements yourself.

Please do not ask us to change this non negotiable policy as refusal may offend.
Have you received Chiropractic care in the past? *This question is required.
Please update us of your previous care: