Romford & Ilford Family Chiropractic LtdTel: 020 8252 1010

313 High Road, Chadwell Heath

Romford, Essex RM6 6AX



Exercise / Work Activity / Reading/Learning / Habits
Heavy / Sitting
Light Labour
Heavy Labour / None
Heavy / Smoking

Have you ever suffered from: (in the boxes below please state how long you have been suffering for)

Blurred Vision
Sleeping problems
Morning tiredness
Energy loss
Ring/buzz in ears
Fainting feeling
Sinus problems
Neck pain
Neck stiffness
Shoulder problems
Upper back problems
Mid back problems
Chest pains
High blood pressure
Low blood pressure
Heart trouble
Stomach trouble
Liver problem
Colon problems
Kidney problems
Bladder problems
Gynecological problems
Prostate trouble
Lower back pain
Low back stiffness
Hip problem
Leg pain

Are you currently taking any medication/Supplements (please specify): ______

Has any physician treated you for any health condition in the last year? Yes  No 

If ‘YES’ what for?______

How would you describe your symptoms? ______


We at the Romford & Ilford Family Chiropractic endeavor to help you to the best of our ability, and although we specialize in the analysis of the structural alignment of the human spine, and its effects on the nervous system, we are not medical specialists. Our purpose is to educate and empower you for a healthier future through spinal care. Every patient should be mindful of his/her own symptoms and should secure the opinions of other health care specialists, should they have any concerns as to the nature of their total condition. Remember – healing takes time.

Payment is expected at the time of each visit. The name of the person above is responsible for payment. I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I agree that any x-ray films taken of me are the property of Romford and Ilford Family Chiropractic Ltd and if I want a copy of these X-Rays a small fee will be charged.

I hereby request and consent to recommended examinations, tests, diagnostic x-ray spinal procedures, adjustments and any other chiropractic procedures and physical therapy techniques, on me.

I understand that my care in this office may involve the making of judgements that are based upon the facts known by the practitioner. Therefore, it is essential that the practice of any healing art is not an exact science, and that no guarantee of results will be made by the practitioner nor relied upon by me. I further understand that the practitioner’s professional expertise lies in detecting and correcting structural and mechanical variations of the body. I agree that he will not be held responsible for the diagnosis or treatment of any medical condition.

I understand that, as with any health care procedure, there are certain complications, which may arise during an adjustment. I do not expect the practitioner to be able to anticipate all risks and complications. I wish to reply on the practitioner to exercise judgement during the course of the procedure(s) which are based upon the facts then known, and are in my best interest.

I realize there are no miracle cures, and I have discussed my options of a future health care plan with my practitioner. I have had all my questions answered to my satisfaction. I hereby give my consent to the recommended spinal/brain care program. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek help. This care is with the practitioners in this centre and/or other future practitioner to render treatment to me while employed by, working for or associated with, or serving as back-up for the centre.

The recommended schedule of care is ______times ______, for ______weeks followed by a review.

I have consented to this program of care and future care. Only if you understand and agree, then please sign below. Please discuss any questions or problems with the practitioner before signing. If signed by parent or guardian, please state: Parent/guardian (please delete as applicable)

Name: ______Signed: ______Date: ______

By practitioner

Name: ______Signed: ______Date: ______

Once completed please hand to reception.

Thank you for choosing Romford and Ilford Family Chiropractic.

We look forward to getting you better and keeping you well.