If you would like to become a patient at Harbourfront Family Chiropractic please complete all fields of the form below. When you have completed the form click on Go and it will automatically be sent to us so we can check the information and print it off ready for your first visit. On your first visit you will be required to sign and date the information you have provided.

Date
Surname
Firstname
Title
DOB (Date of Birth)
Address
Postcode
Phone
Work Phone (inc EXT)
Occupation
E-mail
Marital status	Single Married Divorced Widowed
Sex	Male Female
No. Children
Ages
Private health fund
Will you be claiming insurance	Yes No
Reason for consultation
Whom may we thank for referring you to our clinic?
Your Health Profile
Why this Form is Important - As a full spectrum chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought you to this office, and second, to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Most times the effects are gradual; not even felt until they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to your health potential.
The Early Years (to age 17)
Research is showing that many of the health challenges that occur later in life have their origins during the developmental years, some starting at birth. Please answer the following to the best of your knowledge.
Your Childhood Years (please check box) Yes No Unsure Did you have any childhood illnesses? Did you have any serious falls as a child? Did you play youth sports? Did you take / use any drugs? Did you have any surgery? Have you fallen / jumped from a height of over one metre? (e.g. crib, bed, trees)? Were you involved in any car accidents as a child? Was there any prolonged use of medicine such as antibiotics or an inhaler? Did you suffer from any other traumas (physical or emotional)? Were you vaccinated? As a child, were you under regular Chiropractic care?
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