• What we treat
  • Abdominal Pain
  • Allergy Relief
    • Food Allergies
    • Environmental
  • Anxiety/Hypertension
  • Arthritis
  • Chronic Fatigue
  • Disc Injuries
  • Depression
  • Fibromyalgia
  • Foot, Ankle and Knee Injuries
  • Full Body Pain Management
    • Neck Pain
    • Midback pain
    • Low back pain
  • Headaches/Migraines
  • Infertility Problems
  • Muscle Aches
  • Nutrition
  • Sciatica
    • Skin Conditions
    • Dermatitis
    • Eczema
  • Sleep Disorders
  • Sports related Injuries
  • Sprains and Strains
  • Stress
  • Systemic Conditions
    • Lupus
    • Meniere’s Disease
    • Multiple Sclerosis
    • Parkinson’s
    • Psoriasis
  • Thyroid Disorders
  • Whiplash Injuries
These forms are legal documents and are necessary to bill insurance and are a part of you medical chart. They must be completed in detail so please take your time and ask for assistance if you need help

General Information

Date:

Last Name:

First Name:

Nick Name:

In case of Emergency Notify:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:
Male Female

Gender:

S M D W

Martial Status:

Number of Children:

Date of Birth:
(dd/mm/yyyy)

Age:

Email Address:

Driver License #

Social Security #

Employer Name:

Occupation:

Address of Employer:

City:

State:

Zip:

Name of Spouse:

Spouse's Employer:

Name of nearest relative not living with you:

Address Phone:
YES NO

Is the condition you are here for the result of a work related injury?
YES NO

(If YES, have you reported it to your supervisor?)
YES NO

Is the condition you are here for the result of an automobile collision?

How do you intend to pay for today’s visit?

Do you have health insurance?

YES NO

Insurance Company
(If YES, please provide the receptionist with a copy of your insurance card.)

Name of policy holder

Relationship:

Self Spouse Parent Other
Where you referred to our office?
A friend/relative/coworker/other referred me. Name of person
Other. Please describe source:
(Circle all applicable}I am currently a patient of: Chiropractic NAET Acupuncture
“I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. I understand that this office 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 this office will be credited to my account on receipt. However, I clearly understand that I am responsible for the payment of all services rendered to me if my insurance company, for whatever reason, does not pay for services rendered to me. I also understand that if I terminate my care, any fees for professional services rendered me will become due and payable.”

Date

Patient/Parent/or Guardian Signature
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