WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]
902-407-3400 H
H

902-407-3400

New Adult Patient Health History Form

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

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Sign up using the form below or call 902-407-3400 to make an appointment.

Office Hours

DayMorningAfternoon
Monday9:00am - 12:00m2:30pm - 7:00
TuesdayClosed12:00-7:00pm
Wednesday9:00am - 12:003:00pm - 7:00
Thursday11:007:00pm
Friday9:00am - 1:002:00pm - 6:00pm
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am - 12:00m Closed 9:00am - 12:00 11:00 9:00am - 1:00 Closed Closed
2:30pm - 7:00 12:00-7:00pm 3:00pm - 7:00 7:00pm 2:00pm - 6:00pm Closed Closed