PanAm Patient Registration

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Attending Physician

ID

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Function

Responsible Organization(Required)

Representing Country(Required)

Event Role(Required)

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Sport

Passport Family Name(Required)

Passport Given Name(Required)

Gender(Required)

Date of Birth(Required)

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Place of birth

Email Address

(Optional)

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Home Phone

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Mobile Phone

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Emergency Contact

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Emergency Contact Phone number

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Sport / Main Category

Signature(Required)

Date of Treatment(Required)

Evaluate Pain - VAS_PRE

Region: Other

Working Diagnosis

Comment

Other

Referred to

Evaluate Pain - VAS_POST

Rate the change in how you feel now compared to before this treatment?

Global Perception of Change

My chiropractor thoroughly explained the treatment(s) I received.

My chiropractor treated me respectfully.

My chiropractor answered all my questions.

Overall, I am completely satisfied with the services I received from my chiropractor.

I would return to FICS chiropractors for future services or care.