Date:

First Name: MI:   Last Name:

Address:

Suite/Apt #

City:   State:    Zip Code:  

D.O.B:                                                 SS# - -

Home Phone Number: ( )

Home Phone Number: ( )

E-Mail Address:

Marital Status: Single Married Divorced Separated Widowed

Spouse's Name:

Do you have children? Yes No How many?

Referred by:

Employer's Address:

Suite/Apt #

City:   State:    Zip Code:  

Occupation:

Explain what happened:

Describe the pain and its location:

When did it begin:

Is it getting worse? Yes No Constant Comes and goes

Is it interferring with: Work Sleep Daily Routine

If so, explain:

Have you been treated by a medical physician for this condition?

Yes No

Have you ever been treated by a chiropractor before?

Yes No

Name of chiropractor Phone #

HEALTH HISTORY

Are you taking any of the following medications:

Do you now have or have you ever had any of the following:

Describe any current medical treatment including drugs taken, even though not listed above:

IN EVENT OF EMERGENCY

Contact:

Relationship to you:

Home phone # Work phone #:

Who is your medical doctor: Phone #:

ACCOUNTING INFORMATION

Person ultimately responsibile for your account:

First Name: MI:   Last Name:

Relationship to you:

Billing address:

Suite/Apt #

City:   State:    Zip Code:  

Phone Number: ( )                          SS# - -

D.L. #:  

Work Phone: ( )

Payment method: Cash Check Credit Card

Credit Card (Visa/Mastercard/Other):

Card # Exp. date:

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between providor and patient.

Our policy requires payment in full for all services rendered at the time of the visit, unless other arrangements have been made with the business manager. If your account has not been paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.

By submitting this form you agree to authorize the staff to perform any services needed during diagnosis and treatment. You also hereby authorize the provider and or managed care organization to release any information required to process your insurance claims.

By submitting this form you guarantee that it was completed correctly to the best of your knowledge and that you understand that it is your responsibility to inform this office of any changes to the information you have provided.