Patient Information
Name *
Name
Date Of Birth *
Date Of Birth
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Address *
Address
Emergency Contact Phone
Emergency Contact Phone
Employment Information
Current Symptoms
Date of Injury
Date of Injury
Unable to work from date
Unable to work from date
Date you have or will return to work
Date you have or will return to work
Insurance and Payment for Care
Responsible party phone
Responsible party phone
Primary Insurance Phone
Primary Insurance Phone
Primary Insurance Address
Primary Insurance Address
Primary Insurance Insured's Date of Birth
Primary Insurance Insured's Date of Birth
Secondary Insurance Phone
Secondary Insurance Phone
Secondary Insurance Address
Secondary Insurance Address
Secondary Insurance Insured's Date of Birth
Secondary Insurance Insured's Date of Birth
If in a Auto accident, Please provide:
Insurance Phone
Insurance Phone
Attorney's Phone
Attorney's Phone
Personal Health History
Date of Last Physical Exam
Date of Last Physical Exam
Physician Phone
Physician Phone
Date of last chiropractic visit
Date of last chiropractic visit
Person Incident History:
Checkbox
Family Health History
Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles)
Social History and Life Choices
Reason for Visit
Does this concern interfere with:
Health Problems and Concerns
Please select all that you have had or currently have:
Authorization
I CERTIFY THAT I'M THE PATIENT OR LEGAL GUARDIAN LISTED ABOVE. I HAVE READ/UNDERSTAND THE INCLUDED INFORMATION AND CERITY IT TO BE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I CONSENT TO THE COLLECTION AND USE OF THE AOBVE INFORMATION TO THIS OFFICE OF CHIROPRACTIC. I AUTHORIZE THIS OFFICE AND ITS STAFF TO EXAMINE AND TREAT MY CONDITION AS THE DOCTORS SEE FIT. I HEREBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO ANY INSURANCE COMPANY, ATTORNEY, OR ADJUSTER FOR THE PURPOSE OF CLAIM REIMBURSEMENT OF CHARGES INCURRED BY ME. I GRANT THE USE OF MY ELECTRONIC SIGNED STATEMENT OF AUTHORIZATION WITH MY ELECTRONIC SIGNATURE FOR REQUIRED INSURANCE SUBMISSIONS. I UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME WILL BE CHARGED TO ME, AND I'M RESPONSIBLE FOR TIMELY PAYMENT OF SUCH SERVICES. I UNDERSTAND AND AGREE THAT HEALTH/ACCIDENT INSURANCE POLICIES ARE AN ARRANGEMENT BETWEEN AN INSURANCE CARRIER AND MYSELF. I UNDERSTAND THAT FEES FOR PROFESSIONAL SERVICES WILL BECOME IMMEDIATELY DUE UPON SUSPENSION OR TERMINATION OF MY CARE OR TREATMENT.
CHECK BOX BELOW TO AGREE TO AUTHORIZATION *
Date *
Date