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Have you been, or are you currently under the care of another health care practitioner? (i.e. Chiropractor (other), Naturopath, Physiotherapist, Osteopath, Acupuncturist etc.)
I have reviewed and certify that all the information that I have reported above is correct to the best of my knowledge.
I give my consent to continue with the physical examination and commence care at Outspoken Chiropractic.
Thank you for your time; you're body will thank you for it!
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