Today’s Date___________                 Patient #______________

Patient Information:

Name_________________________________ Age____ Date of Birth__/__/__ Sex___
Address____________________________City___________State_______ Zip___________
Phone(___)_____________ Cell # __________ Marital Status ________
Social Security #______________________
Occupation_________________________________________________

Employer _______________________________________________________________
Employer Address_________________________________________________________
Employer’s Phone______________________
In case of emergency, Notify ________________________Phone___________________
How did you hear about our office?___________________________________________
E-mail_________________________________________
Insurance Information:
INS. CO. Name__________________________________________
Insured’s SS#_______________________________________
Group #____________________________________________
Insured’s Name_______________________________________
Relation________________________________ Insured’s Date of Birth_________
Insured’s Employer_______________________________________________
PLEASE GIVE  THE FRONT DESK YOUR INSURANCE CARD TO MAKE A COPY.
Health Information:
What is you major complaint? ________________________________________
Is this condition due to an A) Auto Accident B) Work Injury C) Other Accident
D) Unknown Cause
Are Symptoms A) Improving B) Getting Worse C) Intermittent-comes and goes
Date Symptom appeared__________
Circle any activities which aggravate your condition A) Standing B) Walking C) Sitting D) Laying E) Lifting F) Twisting G) Coughing
Have you had these symptoms before? (Y/N) If when______________________
Have you seen another doctor for this condition? A) MD B) Chiropractor C) Osteopath
Drs. Name____________________________________ Date Consulted/___/___
Diagnosis_________________________________________________________
I understand and agree that health and accident policies are in arrangement between an insurance carrier and myself. I authorize payment from my insurance carrier directly to this office with the understanding that all monies will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend my care or treatment, and fees for professional services rendered me will be immediately due and payable. In the event of default I promise to pay legal interest on the indebtedness together with such collection costs and reasonably attorney fees as required to effect collections.

Patient’s Signature_______________________________ Date_____________________