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In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

New patients receive $75 first visit including exam,consultation and x-rays!
Some insurance restrictions may apply. Please call for details.

THIS ---->https://daleschiropracticcom.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday8:30am - 12:30pm2:00pm - 6:00pm
Tuesday7:00am -11:00amClosed
Wednesday8:30am - 12:30pm2:00pm - 6:00pm
Thursday8:30am - 12:30pm2:00pm - 6:00pm
Friday7:00am - 11:00amClosed
Saturday
Sunday
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30am - 12:30pm 7:00am -11:00am 8:30am - 12:30pm 8:30am - 12:30pm 7:00am - 11:00am
2:00pm - 6:00pm Closed 2:00pm - 6:00pm 2:00pm - 6:00pm Closed


After Hours: After hours or weekend appointments incur additional fees.

Testimonial

We value our patients' experience at Dales Chiropractic. If you are currently a chiropractic patient, please feel free to complete the following Client Experience Questionnaire. The Questionnaire is in Adobe Acrobat format, and requires the free Acrobat Reader to view.
Download & Print Questionnaire

Dr. Joe Dales
Your Bluefield Chiropractor

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