Confidential Case Review

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Thank you for taking the time to make sure you get the best results possible in the fastest time.

Please complete this Case Review form in its entirety to be considered as a patient at Dr. David J. Clark, DC PA

Dr. Clark will review your digital intake packet, and we will be in contact via email regarding next steps.

PLEASE READ THIS SECTION CAREFULLY

In order for you to get better as fast as possible, we need the help of ALL persons significantly involved in your support system: spouses, children and other family members all play a crucial role in your successful recovery. In short, it is extremely important that everyone is “on the same page.”

Therefore, we require that all persons directly in your support system indicate their encouragement by acknowledging this affidavit.

I (each) the undersigned certify that *

check each box below and list support system names in the next section

I understand that Dr. Clark’s methods and treatment are unique.

I understand that Dr. Clark does not accept every person into his treatment program.

Required

List names of the members in your support system *

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