Please enable JavaScript in your browser to complete this form.Name: *FirstLastWe pride ourselves on excellent service of chiropractic care. Please rate our service and competency: Selected Value: 0 0 = Disorganised and unprepared / 10 = Efficient and knowledgeableRate your level of improvement so far: Selected Value: 0 0 = No change / 10 = Major changeAre there any POSITIVE changes you have noticed since the start of your care? And are there any NEGATIVE changes you have noticed?What things outside of your goals have gotten better, that maybe you didn’t expect?Any positive health surprises?We correct subluxations. How would you define the term 'subluxation' in your own words?Have you noticed any systems of the body functioning better since your subluxations have been reduced (e.g. respiratory, digestive, immune, muscular, reproductive, etc.)? What medications have you been able to reduce the dosage of or stop taking altogether since beginning chiropractic care? Select a patient group:WomenMenChildrenGolden Athletes (60+ Years Old)While most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improved digestionMore regular/comfortable cyclesImproved thyroid functionImproved sexual function/fertilityPositive mood changesLess stressImproved sleep/energyWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Reduced prostate irritationImproved sexual function/fertilityReduced acid refluxImproved digestionImproved sleep/energyPositive mood changesLess stressWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improvement with colicImprovement with earachesImprovement with bed-wettingImproved behaviourBetter gradesAsthma/allergies relievedWhile most chiropractic changes occur near the end of corrective care, we find that many patients can experience great changes sooner, as the nervous system begins to function optimally again. Please select any that you have already experienced:Improved balanceImproved visionImproved coordinationImproved hearingImproved memoryDo you have any questions for the chiropractor regarding your health?What do you like most about our clinic?Would you leave us a Google review?YesNoDo you understand why chiropractic care is important for children?YesNoAs with all private professionals, our practice is built upon referrals. Do you know someone who would benefit from Chiropractic Care?Would you like to give them a code for 50% off their consultation to see if we can help?YesNoSignature: *Clear SignatureSubmit
