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Event Screening Form

Main goal

Describe your main health goal here.
Health Questionaire

a. CONSENT & DISCLAIMERS:

By submitting this form, you consent to being screened at this event, or location.  A general postural analysis and health screen may be performed, including palpation and discussion about chiropractic care and general overall health information. This is not medical advice, and is for general educational purposes. This does not create a Doctor patient relationship. 

If an adjustment takes place, you also agree to the following: you have no serious underlying issues including but not limited to:  cancer, osteoporosis, any surgical fusions or surgeries on the spine, or extremities, or are taking any medications including but not limited to blood thinners, cancer medications, etc.

b. MEDIA DISCLAIMER:
Any media, filming, photo, video, etc. created during this event, is the sole property of Dr. W. Ryan Livingston, and all subsidiaries.  The content may be used for promotional advertising, testimonials, or otherwise marketing purposes.  By submitting this form, you are agreeing to this.

Any treatment is considered only complimentary in exchange for the agreement to assist with marketing and advertising, including but not limited to media as described above, or otherwise.  Once delivered, the treatment care ranges from $250-450 for an initial evaluation if you decide that you do not want to be filmed, or otherwise. You will be charged the normal fee, not the promotional fee.

Screening*
Preferred Date for New Patient Visit
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