New Patient Form

Please fill out this short 4 part form completely. This required form will assist the doctor during your consultation/examination appointment to help determine if you qualify for our successful High-Performance Healing System™ of care.

Please bring all relevant recent diagnostic imaging (MRI, CT Scans, and X-Rays) in DVD disc or film format to your first appointment. These discs can be obtained from the hospital or clinic where you had the imaging performed.  Your family doctor has copies of all of the reports for these tests .  If you have a PocketHealth or MyChart, please send their links and password to the clinic at contact@backclinics.ca before your appointment.

If you prefer not to fill in the form below, you may Click Here to download a fillable PDF version of this Form. Print it, complete it by pen or computer, and bring it along with you to your initial appointment.

Thank you.

New Patient Online Intake Form

Please be sure to complete all Fields.

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How bad does your back/sciatica/stenosis/neck problem feel?

Rate your average pain/discomfort WITHOUT medication on a scale of 1 to 10 (1 = “pain free”, 10 = unbearable pain)

Rate your average pain/discomfort WITH medication on a scale of 1 to 10 (1 = “pain free”, 10 = unbearable pain)

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Have you had an MRI within the last 5 years?

If Yes, do you have a copy of the Images on disc or through a portal such as Pocket Health or MyChart?

Do you have an upcoming MRI scheduled in the near future?

Have you had a CT-Scan or X-rays within the last 5 years?

If Yes, do you have a copy of the Images on disc or through a portal such as Pocket Health or MyChart?

Do you have an upcoming Specialist (surgeon, neurologist etc.) appointment in the near future?