Chiropractic New Patient Registration Form

Name

First NameMiddle NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

E-mail

Date of Birth

MonthDayYear

Sex

Marital Status

Referred By:

Family/Friend's Name

Occupation

Employer

In case of emergency...

Emergency Contact:

First NameLast Name

Relationship

Contact Number

Area CodePhone Number

Your Health Summary (Check all that apply)

Does your Spouse suffer with:

Do your Parents suffer with:

Do any of your Siblings suffer with:

Do any of your Kids suffer with:

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation.

This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please check to indicate you have been made aware of its availability:

Signature

Date