Patient Information

All professional services renedered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments, however, the patient is responsible for all fees, regardless of insurance coverage. All co-pays must be paid during your office visit unless other arrangements have been made in advance with our staff.

Last Name First Name M.I.

Mailing Address Home Phone

City State Zip Code
Social Security Date of Birth Male Female
Employer Address

Work Phone Marital Status S M W D Separated

Student Information




Referring Physician Name
How did you hear about our facility?

Have you seen a Chiropractor for this problem? ________ Physical Therapist_______

What will we treating you for today?

Individual Responsible For Payment If Different From Patient

Last Name First Name M.I.

Mailing Address Home Phone

City State Zip Code

Name of Emergency Contact

Relationship to You Phone Number

 

Primary Insurance Name

Policy Holder Name ID#

Date of Birth Social Security Number

Employer Employer Phone Number

Relationship to Patient (Self, Spouse, Parent, Other)

 

Secondary Insurance Name

Policy Holder Name ID#

Date of Birth Social Security Number

Employer Employer Phone Number

Relationship to Patient (Self, Spouse, Parent, Other)

 

Work Related Injury Information (If Applicable)

Place of Employment When Injured

Contact or Case Manager

Phone Number Claim Number

Address City Zip

Date of Injury Where

Name of Representing Attorney

Address Phone

 

Accident Information (If Applicable)

Place of Employment When Injured

Contact or Adjuster's Name

Phone Number Claim Number

Address City Zip

Name of Insured Policy Number

Name of Representing Attorney

Address Phone