Please enable JavaScript in your browser to complete this form.Name: *FirstLastWe pride ourselves on excellent service of chiropractic care here at Clane Chiropractic. Please rate our service and competency: Selected Value: 0 0 = Disorganised and Unprepared / 10 = Efficient and KnowledgeablePlease rate your level of improvement so far: Selected Value: 0 0 = No change / 10 = Major changeAre there any POSITIVE changes that you have noticed since the start of your care?Are there any NEGATIVE changes that you have noticed since the start of your care? (copy)We correct subluxations in this clinic – how would you define SUBLUXATION in your own words?How are you doing with breaking your bad habits? Grade yourself: Selected Value: 0 Have you noticed any SYSTEMS of the body functioning better since your subluxations have been reduced? Check all that apply:RespiratoryMuscular / SkeletalNervous SystemReproductiveDigestiveSkinBrain FunctionVascularOtherWhat medication have you been able to REDUCE the dosage of or STOP taking since beginning Chiropractic Care?While most of our Chiropractic Miracles occur near the end of Corrective Care, we find that many patients can experience these miracles sooner, as the nervous systems begins to function optimally again. Please check any miracles listed below that you have already experienced:Improved digestionMore regular/comfortable cyclesImproved thyroid functionImproved sexual function/fertilityPositive mood changesImproved sleep/energyReduced prostate irritationImproved sexual function/fertilityReduced acid refluxImproved digestionLess stressImproved balanceImproved coordinationImproved memoryImproved visionImproved hearingImproved behaviourImprovement with colic (CHILD)Improvement with earaches (CHILD)Improvement with bed-wetting (CHILD)Better grades (CHILD)Asthma/allergies relieved (CHILD)Do you have any questions for the Doctor regarding your health?What do you like most about our clinic?Have you liked our Clane Chiropractic page on Facebook?YesYesNo Have you provided us with a Google Review yet?YesYesNoHave any of your family members been checked by a Chiropractor?YesYesNoWould you like to take advantage of our complimentary family check-up?YesYesNoSubmit
