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For Your First Visit

adult intake form

Adult Intake Form

Age 14 +

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child intake form

Child Intake Form

Age 5 - 13

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infant intake form

Infant Intake Form

Age 0 - 4

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Goal

Our goal at Tillsonburg Chiropractic and Wellness Clinic is to eliminate every bit of apprehension you may have visiting a chiropractor for the first time.

Since chiropractic care involves a series of visits, each one building on the one before, it’s important that our relationship can go the distance. One of the best ways to have successful patient relationships is to explain everything in advance. The more you understand who Dr. Fatima Korah is and what she does, and why she does it, the better results you’ll enjoy.

Remember . . .
If you have x-ray reports or MRI/CT reports, please bring them along. Depending on the results of these preliminary tests, Dr. Korah may recommend x-rays be taken.

Please plan on approximately one hour for your first visit.