Chiropractor

NEW PATIENT REGISTRATION

WELCOME: The doctor and staff welcome you and want you to provide you with the best possible care. We will conduct a thorough history and physical examination to decide if we can assist you. If we do not believe that your condition will respond to our care, we will refer you to the appropriate healthcare provider. If you are a candidate for care in this office, then a treatment plan will be recommended to fit your individual needs.

 

INSTRUCTIONS: Please complete the following information in its entirety. The information submitted on this form is strictly confidential. If you have difficulty understanding any portion of this for, please ask for assistance. If the question does not pertain to you, simply write in NIA for non-applicable.

PLEASE FILL OUT THIS FORM ENTIRELY. YOUR ANSWERS DO NOT SAVE UNTIL YOU CLICK SUBMIT AT THE END OF THE FORM. THIS FORM SHOULD TAKE APPROXIMATELY 10 MINUTES TO FILL OUT.

OFFICE HOURS

Monday: 10-1, 3-6
Tuesday 3-7
Wednesday 10-1, 3-6
Thursday CLOSED
Friday 10-1, 3-6
Saturday* 8:30-10:30

LOCATION

70-50 Austin St #108

Forest Hills, NY 11375

Note: THE OFFICE IS NOW OPEN FOR REGULAR OFFICE HOURS, BUT YOU WILL NEED TO MAKE AN APPOINTMENT TO BE SEEN. WE ARE CURRENTLY NOT HAVING OPEN OFFICE HOURS. WE FOLLOW STRICT CDC PROTOCOL WITH CLEANING AND SOCIAL DISTANCING. ****IF YOU FEEL YOU HAVE BEEN IN CONTACT WITH ANYONE THAT HAS THE CORONAVIRUS, OR, IF YOU ARE EXPERIENCING SYMPTOMS YOURSELF, PLEASE SEE YOUR PRIMARY CARE DOCTOR BEFORE COMING TO THE OFFICE. WE ARE DEDICATED TO TAKING CARE OF OUR PATIENTS IN THE SAFEST MANNER POSSIBLE*****

© Dr. David Kesselman Chiropractor.  All Rights Reserved. Website design by Jamie Cohen.