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Tooting Children's Assessment

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 5 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 020 8767 6718.
Childs Personal Details *This question is required.
This question requires a valid date format of DD/MM/YYYY.
calendar
Parents Names & contact details (please place NA if not applicable) *This question is required.
Siblings Names and Ages
Childs primary Address? *This question is required.
How did you find us? *This question is required.
Do you have health insurance that will contribute to 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, BUPA or AXA PPP. 

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 with us and we will gladly issue you a receipt so you may claim back any entitlements yourself.
Have you or your child received Chiropractic care in the past? *This question is required.
Could you please provide the following details regarding your/your child's previous chiropractic experience: *This question is required.