Please take your time in filling out this application and fill out as much of it as you are able.
It will assist us in accurately diagnosing your condition and assessing your treatment.

Once your application has been received, you will be called
within the next business day to book a consultation with Dr. Liem.

Thank you and we look forward to meeting you.

Application For Admission - part 1
Name: XX Sex: Male Female
Age: X Birthday: X / X / X Month / Day / Year
Address: X City: X
Province: X Postal Code: X
Home Phone: XX Work Phone:
Cell Phone: Email Address
Best place to reach you (please check one):
Home: Work: Cell:
May we leave a message for you?: Yes: No:
How did you hear about the Premium Spinal Care? XX
Interested in Which Location: X

Application For Admission - part 2
What is your main problem/symptom(s) prompting your request for a consultation with the Doctor today?    
X    
Would you consider this problem (circle one)....    
MINIMAL (Annoying but causing NO limitations)    
SLIGHT (Tolerable but causing a little limitation)    
MODERATE (Sometimes tolerable but definitely causing limitations)    
SEVERE (Causing Significant limitations)    
EXTREME (Causing near constant (>80% of the time) limitations)    
Is this condition something you are willing to live with or are you at a point where you are ready to try to correct the problem?    
X    
   
What are you hoping happens today as a result of your consultation with the Doctor?    
X    

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