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Welcome to Centre-Ville Chiropratique

Please take a few moments to fill out our online form before your first visit. All information will be kept confidential.

    Personal Information

    Date (obligatory)

    Gender (obligatory)

    First name (obligatory)

    Last name (obligatory)

    Adress (obligatory)

    City (obligatory)

    Zip code (obligatory)

     

    We need at least one phone number.
    Your cell phone number will be used to find your account
    or to receive appointment reminder text messages.

    Email (obligatory)

    Cell phone (obligatory)

    Residence phone

    Work phone

    Extension

    Birth date (obligatory)

    Age

     

    How did you hear about our clinic?



    Others

    Job/Profession (obligatory)

    Employer

     

    Reason of the consultation

    Reason of the consultation (obligatory)

    Do you feel rested in the morning?

    How is your energy level during the day?

    How is your digestion?

    How fast do you eat?

    What do you usually eat from the time you get up until you go to sleep? (Please specify times, amounts and details of a "typical" daily meal)

     

    Health condition

    Are you taking any medications? (obligatory)

    Have you been hospitalized? (obligatory)

    Have you had in the past or do you currently have any problems with:

    Allergy
    Thyroid gland disease
    Anemia or blood disease
    Arthritis or rheumatism
    Cancer, cyst or tumor
    Cracking or pain in the jaw
    Depression or anxiety
    Diabetes or hypoglycemia
    Bruises (easy bruises)
    Numbness
    Sprain, tendonitis or bursitis
    Epilepsy or convulsions
    Dizziness or vertigo
    Fatigue
    Fracture
    Chills or fever
    High or low blood pressure
    Urinary or fecal incontinence

    Insomnia
    Skin disease
    Neck pain
    Back pain
    Headaches or migraines
    Nausea
    Oedema (swelling)
    Recent weight loss or gain
    Gastric Reflux
    Eye or ear problems
    Heart problems
    Respiratory problems
    Digestive disorders
    Hormonal disorders
    Kidney problems, kidney stones
    Blood in the urine or stool
    Urinating frequently
    Prostate disorders

     

    Section reserved for women

    Are you pregnant?
    What is your expected delivery date?

     

    Lifestyle habits

    Do you smoke? (obligatory)

    What is your sleeping position? (obligatory)

    Are you physically active?

    Adequate work station?

    What is the quality of your diet? (obligatory)

    Quantity of alcohol per week

    Quantity of coffee per day

    Number of glasses of water per day

    Stress level (obligatory)

    How important is your health to you? (0=not at all, 10+priority) (obligatory)

    Communication by email and sms

    Consents (obligatory)

    Accuracy of the information (obligatory)

    Credit card payment authorization (obligatory)
    Because the service is a virtual consultation, your credit card information will be requested at the time of the appointment in order to bill you for the services after your consultation. This payment information is confidential.

    Privacy and Sharing of Personal Information (obligatory)
    I authorize the clinic and its associated professionals to collect my personal and medical information as indicated above, to communicate this information among the various professionals of the clinic and to communicate with my family physician and/or referring physician to discuss my treatments. I also understand that my personal and medical information is confidential and will only be shared with third parties with my permission.

    Cancellation Policy (obligatory)

    To book your appointment online, you will need to provide your credit card information. This information is confidential. A late cancellation or missed appointment leaves a gap in the professional's schedule that could have been filled by another patient. Therefore, we require 24 hours notice for all cancellations or changes to appointments, otherwise, we will charge the full consultation fee as a cancellation or missed appointment fee to all patients who do not give at least 24 hours notice.