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Screening Survey – The Chiro Place – Midtown

by | Jun 16, 2022

Displaying 1 - 25 of 57

Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:
08/10/2022Maishea SibleyEmail hidden; Javascript is required.(901) 310-079608/23/202211:00 AM

CATO AO

  • Back Pain
08/19/2022Margret HoltonEmail hidden; Javascript is required.(901) 341-963209/03/202211:00 AM

Northwest Prep AO
will pay at appt.

  • Back Pain
08/19/2022Lois SimmonsEmail hidden; Javascript is required.(901) 426-927808/20/202211:00 AM

Northwest Prep AO
will pay at appt.

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Shoulder/Arm Pain
08/25/2022Tia SimmonsEmail hidden; Javascript is required.(865) 936-027409/08/202206:00 PM

AGAPE AO

Will pay at clinic

  • Neck Pain
  • Numbness/Tingling
08/29/2022Torrey BatesEmail hidden; Javascript is required.(678) 492-090708/31/202208:30 AM

Raleigh Love Day AO
Will Pay At Clinic

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
09/03/2022Latasha SagoEmail hidden; Javascript is required.(901) 212-834909/22/202208:30 AM

CTH 5K AO PAID

  • Headaches/Migraines
09/13/2022Bernadette CarterEmail hidden; Javascript is required.(901) 585-528209/20/202206:00 PM

MLK Prep

  • Neck Pain
  • Shoulder/Arm Pain
09/13/2022Toykela BlanchEmail hidden; Javascript is required.(205) 534-864009/20/202206:00 PM

MLK Prep

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Ear Aches
  • Hip/Leg Pain
  • Headaches/Migraines
  • Disc Problems
  • Numbness/Tingling
  • Shoulder/Arm Pain
09/13/2022Gregory StallingsEmail hidden; Javascript is required.(901) 479-696009/20/202203:30 PM

MLK Prep

Will pay at appointment

  • Back Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Shoulder/Arm Pain
09/13/2022Jebori ThomasEmail hidden; Javascript is required.(901) 664-855210/10/202211:00 AM

MLK Prep

Will pay at clinic

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
09/14/2022Nishelle SmithEmail hidden; Javascript is required.(901) 482-424909/15/202208:30 AM

For The Kingdom
Referred by Torrey Bates

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
09/17/2022Regina Berry-SeymourEmail hidden; Javascript is required.(901) 857-926509/21/202209:00 AM

Brown Health Fair
Will pay at appt
Lupus patient

  • Back Pain
  • Neck Pain
  • Sinus/Allergies
  • Hip/Leg Pain
  • Headaches/Migraines
  • Disc Problems
  • Numbness/Tingling
  • Shoulder/Arm Pain
09/17/2022DaShundra AveryEmail hidden; Javascript is required.(901) 585-846009/29/202206:00 PM

Brown Health Fair
Will pay at clinic

  • Back Pain
09/24/2022Victor JacksonEmail hidden; Javascript is required.(901) 659-343210/04/202209:00 AM

Remington College

  • Back Pain
  • Hip/Leg Pain
09/24/2022Jazzmyne FentressEmail hidden; Javascript is required.(901) 268-292709/27/202206:00 PM

West side Elementary
Will pay with FSA

  • Back Pain
10/07/2022Donald CurryEmail hidden; Javascript is required.(601) 934-971810/13/202206:00 PM

Lakeside Conference

Paid (debit)

  • Neck Pain
10/08/2022Daisha HamiltonshippEmail hidden; Javascript is required.(901) 921-052810/12/202210:30 AM

Connect center oct 8
New patient
Paid cashapp

  • Neck Pain
10/08/2022Tiffany ClayEmail hidden; Javascript is required.(901) 355-287010/18/202203:00 PM

New patient Shawn
Debit paid
Connect center

  • Back Pain
10/18/2022Tamika AbregoEmail hidden; Javascript is required.(770) 820-788210/20/202206:00 PM

New patient bre

Dental connection

Cash app paid

  • Back Pain
  • Neck Pain
10/19/2022Brittany BrattonEmail hidden; Javascript is required.(901) 277-947410/27/202203:30 PM

Power Center High School
PAID AO

  • Back Pain
  • Neck Pain
  • Headaches/Migraines
10/19/2022Bryan HornEmail hidden; Javascript is required.(901) 258-278111/02/202204:00 PM

Power Center High School
PAID Debit AO

  • Back Pain
  • Neck Pain
10/19/2022Christian GordonEmail hidden; Javascript is required.(404) 312-461810/27/202209:00 AM

Powerhouse academy

Friday invoice

AO

  • Neck Pain
  • Sinus/Allergies
10/22/2022William WoodardEmail hidden; Javascript is required.(901) 647-727810/25/202211:00 AM

The Walk AO
Will pay at clinic (older patient)

  • Back Pain
  • Neck Pain
  • Hip/Leg Pain
  • Headaches/Migraines
  • Numbness/Tingling
  • Sciatica
10/22/2022Tariq SmithEmail hidden; Javascript is required.(901) 921-676211/02/202208:30 AM

The Walk AO

PAID Debit

  • Back Pain
10/22/2022Sharonda DeanEmail hidden; Javascript is required.(901) 230-371910/25/202206:00 PM

Soulsville charter school

Np bre

Paying with fsa

  • Back Pain
  • Shoulder/Arm Pain
Screening DateNameEmailPhoneAppointment DateAppointment TimeNOTES: (office use only)Recently Experienced Symptoms:

Displaying 1 - 25 of 57