Patient Information
In order to provide you the best possible chiropractic care, please complete this form and
bring it to your first appointment. All information is strictly CONFIDENTIAL.
Patient Data
Name ______________________________ Date ________ Referred by ________________________
Mailing address
Address __________________________________________________________________________________
City ______________________ State ____________________ Zip ____________________________
Telephone (work) ____________ (home) __________ E-mail ____________________________
Age ______ Birth date __________ Social Security # ______________ Number of children ______
Occupation ____________________________ Employer________________________________________
Marital Status __________ Spouse’s name ________________ Spouse’s Occupation ______________
Spouse’s employer ______________________ Spouse’s health status ____________________________
Emergency contact __________________________________________ Phone ______________________
Current Complaints
Nature of injury: Automobile* ! Work ! Other !
Please describe ____________________________________________________________________________
________________________________________________________________________________________
Date of injury ______________ Date symptoms appeared ______________
Have you ever had same condition? ! No ! Yes If yes, when? ________________________________
List other practioners seen for this injury/condition ________________________________________________
Have you ever been under chiropractic care? ! No ! Yes
If yes, please describe ______________________________________________________________________
Insurance Information
Name of party responsible for payment __________________________ Phone ______________________
Do you have health insurance? ! No ! Yes Name of company ____________________________
* If an auto accident please provide:
Insurance company name __________________________ Contact person ________________________
Phone ________________________________ Claim # __________________________________
Billing Address ________________________________________________________________________
Name of the insured ________________________________________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier
and myself. I understand and agree that all services rendered to me and charged are my personal responsibility
for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional ser-
vices rendered to me will be immediately due and payable.
Patient’s signature ______________________________________________ Date ____________________
Spouse’s or guardian’s signature __________________________________ Date ____________________
