Cardiff Bay Chiropractic
36 West Bute Street
Tel: 02920 451603

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information


Authorization

1) I certify that I'm the patient or legal guardian listed above. 2) I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. 3) I consent to the collection and use of the above information to this office of chiropractic. 4) I authorise this office and its staff to examine and treat my condition as the doctors see fit. 5) I grant the use of my signed statement of authorisation with my signature for required insurance submissions. 6) I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. 7) I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. 8) I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.9) I consent for Cardiff Bay Chiropractic to take a photo of me and I understand that Cardiff Bay Chiropractic need the use of my photo for recognition purposes only.10) I understand that the photo will not be used in any other way other than for my personal files unless agreed by myself.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


Finalizing Form



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