Address: _________________________City: ______________ State: ___
Zip: _____
Home Phone: (____)__________Cell: (____)___________Work: (____)____________
E-Mail Address (for our newsletters): ________________________________________
Social
Security Number: ______________________ Birth date: _____/_____/_______ Age: _________
Marital
Status: S M D W
Spouse’s Name: ____________________ Occupation: _____________
Patient’s
Employer/Business: __________________________
Occupation: _______________
Hobbies/Activities:
__________________________________________________________________
Spinal health
is especially important during pregnancy. Is there a chance you are pregnant? YES
NO
Have you previously been under chiropractic care? Y
N Date of last visit: _____/______/_________
Primary Health
Insurance Company Name: _______________________________________________
ID
#: _____________________________ Phone Number: ______________________
(If
Applicable) Secondary Health Insurance Company Name: ___________________________________________________
ID #: __________________________ Phone Number:_________________________
Terms
Of Acceptance
OUR PRACTICE OBJECTIVE is to eliminate any major interference to the expression
of the body’s innate wisdom. Our methods typically include specific adjustments, therapeutic exercises, and muscle work.
I authorize the Doctor to provide any forms
of evaluation, x-rays and treatment that may be indicated in connection with the patient above, and further authorize and
consent that the Doctor chooses and employs such assistance as he sees fit. I also understand that prior to care, full explanation
of procedure(s) involved will be given. I agree to pay all services rendered in this office.
I authorize the release of any and all information to any insurance company, attorney,
or adjuster in order to process claims for reimbursement for chiropractic charges rendered in this office.
Signature:
___________________________________ Date: ______/ _____/ ______
Relationship
to Patient: _________________________________
