Name(Required) First Last Describe the condition for which you consulted Adjusted Life for. What symptoms were you experiencing?On a scale of 1-10, with 10 being the worst, how severe was your pain?Please enter a number from 1 to 10.How long have you had this pain? Days Weeks Months Years Were you treated by any other doctors for this condition? Yes No What medications if any, helped alleviate your symptoms? Did you have any doubts that a chiropractor could alleviate your symptoms? Yes No What were your first impressions of our office and working with Dr. Coty?Describe your results including the time it took to heal.Did you know anyone who had used a chiropractor before you made your first appointment? Yes No Would you recommend chiropractic care to others who are sick, suffering or in pain? Yes No Please attach a photo of you doing something you were once not able to do because your pain was too severe.Accepted file types: jpg, jpeg, gif, png, Max. file size: 1,000 MB.For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Adjusted Life Chiropractic, or anyone authorized by Adjusted Life Chiropractic, of any and all photos/videos which you have this day taken of me (or I have provided), for the purposed of promotional TV and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Adjusted Life, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act Laws). *(Required) I agree to the terms and conditions.
