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Thank you for considering care at

the ChiroDrs @ Rapha Clinic,

an Integrative Healthcare Centers.

​

Please complete the following questionnaire to effectively and efficiently offer and

schedule your First appointment with us.

2. What is the intensity of your current condition (0-10)?
3. Is the condition worse in the morning or evening?
9. What is your preferred Adjustment Technique ?
10. Where is your Preferred Location? (check all that apply)
11. When is your preferred days and times for your appointment? (check all that apply)
12. Do you have a health insurance plan?
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