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Chiropractic
>
Techniques and Therapies
Custom Orthotics & Footwear
Massage Therapy
>
Massage Therapy Treatment Options
Chronic Pain Counselling
Meet Our Team
Chiropractors
>
Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
>
Dr. Jenna Press BScH, DC, Medical Acupunture
Massage Therapists
>
Ariane Gionet, RMT
Clinic Supervisor
FAQs
Contact
Gallery
Videos
Excercises
New Patient Intake Form
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Indicates required field
Name
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First
Last
Email
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Primary Phone Number
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Secondary Phone Number
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Address
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Line 1
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City
State
Zip Code
Country
Birthday (mm/dd/yyyy)
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Occupation
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Emergency Contact Information
Name (First and Last)
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Relationshipt to you
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Phone Number
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Health Information
MSI Health Card Number
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Family Doctor
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Insurance Information
Insurance Compay
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Policy or Plan Number
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Identification Number
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Credit Card Information
We process all payments and co-pays not covered by your health insurance through your credit card
Name on Card
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Card Number
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Expiry mm/yyyy
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CVV
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Reason for Today's Appointment
Primary complaint(s)
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What makes your complaint better?
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What makes your complaint worse?
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When did your complaint begin?
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Rate your complaint (0=no pain, 10=exruciating pain)
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0
1
2
3
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5
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7
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9
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Is your complaint worse in the:
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Morning
Daytime
Evening
Night
Is your complaint getting:
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Better
Worse
Same
Health History
Do you have any allegeries? If so, please list and indicate severity.
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List your medications, vitamins, supplements.
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List your surgeries, hospitalizations.
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If you smoke or vape, how many per week?
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If you drink alcohol, how many servings per week?
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Present and Past Health Issues
Please indicate and provide a brief description of any present or past health issue, condition or symptom(s).
Muscular (muscles, tendons, ligaments)
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Skeletal (bones, joints)
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Nervous (brain, nerves)
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Endocrine (hormones)
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Integumetary (skin, hair, nails, sweat glands)
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Immune
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Circulatory (heart)
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Urinary & renal (kidneys, bladder)
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Respiratory (lungs)
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Reproductive (female and male sex organs)
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Digestive (stomach, intestines)
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Family Health History
What health conditions does your family members have? (Grandparents, parents, siblings, children, etc).
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Fees and Policies
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Submit
Chiropractic
45-60 minute Initial Chiropractic Appointment $170
30 minute Chiropractic Appointment $100
15 minute Chiropractic Appointment $75
Orthotics $500
Massage Therapy
30 minute Appointment $75
45 minute Appointment $95
60 minute Appointment $105
90 minute Appointment $165
Home
Book An Appointment
Services
Chiropractic
>
Techniques and Therapies
Custom Orthotics & Footwear
Massage Therapy
>
Massage Therapy Treatment Options
Chronic Pain Counselling
Meet Our Team
Chiropractors
>
Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
>
Dr. Jenna Press BScH, DC, Medical Acupunture
Massage Therapists
>
Ariane Gionet, RMT
Clinic Supervisor
FAQs
Contact
Gallery
Videos
Excercises