New Patient Forms

Are you a new patient at Back-in-Action? We’d be delighted if before your visit you could download these forms and fill in the details about your problem (Chiropractic New Patient Registration – Adult) and your medical history (Chiropractic New Patient Medical History Form – Adult).

Before we can start to help you get better, it is important that you are aware of any possible risk or side effects that might be associated with the treatments we use. Please read through our Informed Consent Information.

If you’ve had a road traffic accident please can you also fill out our Accident Report Questionnaire.

Most of these forms are a bit of a marathon but it’s worth the effort because they provide us with loads of useful information to help you get better.

We have specific forms for younger children – Chiropractic New Patient Registration – Children.

Please bring the forms you need with you when you come in for your New Patient Consultation. They are a bit of a marathon so we recommend filling them in gradually. Probably if you were pushed they might take 20-30 minutes to fill them in properly.

Please click on the form to download the document…

Chiropractic New Patient Registration - Adult
Chiropractic New Patient Registration – Adult
Chiropractic New Patient Medical History
Chiropractic New Patient Medical History
Traffic Accident Report Questionnaire
Traffic Accident Report Form
Chiropractic New Patient Registration - Child
Chiropractic New Patient Registration – Child
Informed Consent Information
For information on our privacy and data protection policy, please follow the link.

If you have any questions please contact the clinic on 01772 749389 or email us on reception@back-in-action.com.

Thanks.

From the Preston Chiropractor Team
Getting You Back in Action & Enjoying Your Life Again
Serving the people of Preston and surrounding areas including Southport and Lytham St Annes