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Request an Appointment

845-517-0520

APPLICATION FOR CARE

NEW LIFE FAMILY CHIROPRACTIC HEALTH HISTORY FORM

Please fill out this form as completely and accurately as possible.

PERSONAL DATA

PLEASE READ AND SIGN BELOW

The information I have provided, on this case history form, is true and accurate, to the best of my knowledge. I give Dr. Craig Nugent and Dr. Christina Petersen permission to render care to me today. This initial visit includes a health history/consultation, chiropractic exam/evaluation, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Thank you for choosing New Life Family Chiropractic.

We look forward to helping you.

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