Intake form

Name *

Email address *

Phone number

What is your primary reason for visiting our clinic?

Please select at least one option.

Back pain

Neck pain

Herniated disc

Sciatica

Migraines

Sports injury

Postural issues

Have you previously received chiropractic care?

What treatments are you interested in?

Please select at least one option.

Spinal adjustments

Cervical decompression

Lumbar decompression

Shockwave therapy

PEMF therapy

Vibration plate therapy

Do you have any existing medical conditions? if yes, please specify.

Are you currently taking any medications? if yes, please list them.

How did you hear about us?

Preferred appointment date and time

Additional questions or comments

Rancho Murieta Spine & Disc Center