New Patient Form

ACCT#*

Date*

Name*

Home Phone*

Address*

City/State/Zip*

Age*

Birth Date*

Martial Status*

No of Children*

Name of Spouse*

Email Address*

Cell Phone*

Social Security Number*

Driver License Number*

Occupation*

Employer*

Address*

Office Phone*

Who should we contact in case of Emergency?*

Phone Number*

WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?*

Have you been treated for any other health condition by a physician in the last year?*

Reason for this Appointment*

Have you seen a chiropractor for this or any other condition?*

If so, when was your last visit?*

PAYMENT IS EXPECTED AT THE TIME OF VISIT! Will you be paying today by:*

CASH

CHECK

CREDIT CARD

Are you Insured?*

YES

Insurance Co*

Phone Number*

Primary Insured’s Name*

DOB*

Relationship*

SELF

SPOUSE

CHILD

OTHER

Subscriber ID*

Group #*

Employer*

I understand and agree that health and accident insurance policies are an arrangement between insurance carrier and myself. Furthermore, I understand that FAMILY CHIROPRACTIC CENTER will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to FAMILY CHIROPRACTIC CENTER will be credited to my account upon receipt. However, I clearly understand and agree that any services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment. Any fees for professional services rendered me will be immediately due and payable.

Patient Signature or Parent/Legal Guardian*

Date*

Name

This field is for validation purposes and should be left unchanged.

WELCOME TO OUR OFFICE!

Contact Info

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