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512-906-2682
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NEW PATIENT OFFER!

$47 Exam & Adjustment ($90 value)

(Offer Excludes Medicare & Other Federally Funded Programs.)

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Signatures

I understand and agree that all services rendered to me and charged are my personal responsibility and are due at the time services are rendered. I understand that MySpine Chiropractic Center does NOT accept MEDICARE or participate with any insurance carriers.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Featured Services

Conditions
Learn more about some of the common conditions we treat in our office.
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Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.