Etio Chiropractic Health Profile
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- Melvyn Hunter
- 5 years ago
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1 Eti Chirpractic Health Prfile Persnal Infrmatin Name Street Address City State Zip Birth Date Date Primary Phne Secndary Phne Gender Marital Status Occupatin Family member name(s) and age(s): Hw did yu hear abut Eti Chirpractic? Current Health Cncern(s) Health Cncerns List accrding t severity Present Severity =mild 10 =unbearable When did this episde start? If yu had this cnditin befre, when? Did the prblem begin with an injury? Y/N Are the symptms cnstant r intermittent? I d nt have any current health cnditins and seek wellness / maintenance / preventative care. Infrmatin regarding yur current health prblem(s) Since it started, is this cnditin getting better, wrse, r staying the same? What relieves yur symptms? What makes them feel wrse? What daily activities are restricted by yur current health prblems? Carrying grceries Lift/play with children Static standing Yard wrk Sitting t standing Read r cncentrate Walking Garbage Climbing stairs Shwer Husehld Chres Dress Caring fr pets Shave Laundry Drive Cmputer use Extended Sitting Exercise Sleep
2 Prvider Histry Have yu been t a chirpractr befre? Yes N Wh & When? Have yu seen any ther dctrs fr this cnditin? If yes, wh? Please list any medicatins yu are taking and what they are fr: Please list any brken bnes, surgeries, r hspitalizatins yu have had and when: Select all current prblems yu have Dizziness Thrat Issues Kidney Prblem Liver Disease Nervusness Headaches Thyrid Prblems Mid Back Pain Shulder Pain Epilepsy Vertig Asthma Irritable Bwel Chrnic Fatigue Disc Prblem Ear Infectins Ulcers Sciatica Lupus Infertility Nausea Numbness in arms Numbness in Legs Fibrmyalgia Acid Reflux TMJ Numbness in hands Numbness in Feet Chest Pain Migraines Neck Pain Menstrual Disrder Lw Back Pain Arm Pain Diabetes Anxiety High Bld Pressure Incntinence Leg Pain Chrnic Sinus Stmach Disrder Hip Pain Knee Pain Did/D yu have any f the fllwing? Strke Cancer Heart Disease Spinal Surgery Seizures Spinal Bne Fracture On a scale f 1 t 10, with 10 being the highest, rate yur cmmitment t restring yur health: Yur Gals Please state yur tp three life gals Example: Get rid f migraines by 6/15 s I can play with my kids again Name Date
3 Practice Member Infrmatin (Must Be Cmpleted Befre Services Can Be Rendered) NAME: FIRST MIDDLE LAST SOCIAL SECURITY NUMBER CONTACT IN CASE OF EMERGENCY Phne # NAME OF PRIMARY INSURANCE CARRIER Name f Insured Insured Date f Birth Insured Scial Security Number NAME OF SECONDARY INSURANCE CARRIER Name f Insured Insured Date f Birth Insured Scial Security Number: Insurance Plicies and Fee Schedule Cnsultatin- includes practice member histry. This service is cmplimentary Assessment (new r established practice member)- includes ne r mre f the fllwing: thermgraphy, surface electrmygraphy, range f mtin, mtin and/r static palpatin, leg check $50-$75. Chirpractic Adlustment- The actual re-alignment f the vertebra dne by hand. Often a sund will be heard, but if there is n auditry result, it des nt mean that the adjustment has nt taken place. $40-$60. X-rays- Specific x-ray views taken f yur spine t determine a misalignmenvsubluxatin f yur vertebrae. These can als be used t indicate prgress after perid f care. $40 per view. Release f Authrizatin/Assignment f Benefits I authrize and request payment f insurance benefits directly t Kent Daavettila DC. I agree that this authrizatin will cver all services rendered until I revke the authrizatin. I agree that a phtcpy f this frm may be used in place f the riginal. I understand that all prfessinal services rendered are charged t the patient and that It is custmary t pay fr services when rendered unless ther arrangements have been made in advance. I understand that I am financially respnsible fr charges nt cvered by this assignment and that Eti Chirpractic reserves the right t add a $25.00 service charge t my accunt fr any returned check r charge back. I authrize this facility alng with any billing service and their cllectin agency r attrney wh may wrk n their behalf, t cntact me n my cell phne and/r hme phne using pre-recrded messages, artificial vice messages, autmatic telephne dialing devices r ther cmputer assisted technlgy, r by electrnic mail, text messaging r by any ther frm f electrnic cmmunicatin. Signed Date
4 Terms f Acceptance In rder t prvide fr the mst effective healing envirnment, mst effective applicatin f chirpractic prcedures, and the strngest pssible dctr-patient relatinship, it is ur wish t prvide each patient with a set f parameters and declaratins that will facilitate the gal f ptimum health thrugh chirpractic. T that end, we ask that yu acknwledge the fllwing pint regarding chirpractic care and the services that are ffered thrugh this clinic: A. Chirpractic is a very specific science, authrized by law t address spinal health cncerns and needs. Chirpractic is a separate and distinct science, art and practice. It is nt the practice f medicine. B. Chirpractic seeks t maximize the inherent healing pwer f the human bdy by restring nrmal nerve functins thrugh the adjustment f spinal subluxatin(s). Subluxatins are deviatins frm nrmal spinal structures and cnfiguratins that interfere with nrmal nerve prcesses. C. The chirpractic adjustment prcess, as defined in the law f this jurisdictin, invlves the applicatin f a specific directinal thrust t a regin r regins f the spine with the specific intent f re-psitining misaligned spinal segments. This is a safe, effective prcedure applied ver ne millin times each day by dctrs f chirpractic in the United States alne. D. A thrugh chirpractic examinatin and evaluatin is part f the standard chirpractic prcedure. The gal f this prcess is t identify any spinal health prblems and chirpractic needs. If during this prcess, any cnditin r questin utside the scpe f chirpractic is identified, yu will receive a prmpt referral t an apprpriate prvider r specialist, accrding t the initial indicatins f the need. E. Chirpractic des nt seek t replace r cmpete with yur medical, dental r ther type(s) f health prfessinals. They retain respnsibility fr care and management f medical cnditins. We d nt ffer advice regarding treatment prescribed by thers. F. Yur cmpliance with care plans, hme and self-care, etc., is essential t maximum healing and ptimal health thugh chirpractic. G. We invite yu t speak frankly t the dctr n any matter related t yur care at this facility, its nature, duratin, r cst, in what we wrk t maintain as a supprting, pen envirnment By my signature belw, I have read and fully understand the abve statements. All questins regarding the Dctr's bjectives pertaining t my care in this ffice have been answered t my satisfactin. I therefre accept chirpractic care n this basis. (Signature) (Date) Ntice f Privacy Practices Acknwledgment I understand that I have certain rights f privacy regarding my prtected health infrmatin, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPAA). I understand that this infrmatin can and will be used t: 1. Cnduct, plan and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly. 2. Obtain payment frm third-party payers. 3. Cnduct nrmal healthcare peratins, such as quality assessments and physicians certificatins. I acknwledge that I may request yur NOTICE OF PRIVACY PRACTICES cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I als understand that I may request, in writing, that yu restrict hw my private infrmatin is used t disclsed t carry ut treatment, payment, r healthcare peratin. I als understand yu are nt required t agree t my requested restrictins, but if yu agree, then yu are bund t abide by such restrictins. (Signature) (Date)
5 INFORMED CONSENT FOR CHIROPRACTIC CARE CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE. PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEAL TH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEAL TH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE. I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT. PRINT PRACTICE MEMBER'S NAME HERE PRACTICE MEMBER'S SIGNATURE OR GUARDIAN SIGNATURE IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW WRITTEN CONSENT FOR A CHILD NAME OF PRACTICE MEMBER WHO IS A MINOR/CHILD I AUTHORIZE DR. KENT DAAVETTILA AND ANY AND ALL ETIO CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD. AS OF THIS, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY ETIO CHIROPRACTIC. GUARDIAN SIGNATURE AND RELATIONSHIP TO MINOR/ CHILD WITNESS SIGNATURE (OFFICE STAFF)
6 X-RAY AUTHORIZATION AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS IN OUR FILES. THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS $ THIS FEE MUST BE PAID IN ADVANCE. DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY. PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF ETIO CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE. BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS. PRINT YOUR NAME HERE SIGNATURE YOUR AGE FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT ETIO CHIROPRACTIC. SIGNATURE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE Sex: DMD F D Lat Cervical D Flex/Ext D Lwer Cervical D Lateral Thracic D A-P Thracic CM Kvp Time MAS CM Kvp Time MAS CM Kvp Time MAS CM Kvp Time MAS D / D / D 1/15 20 D / D 01/20 15 D D 02/ D 01/10 30 D D 01/ /15 20 D / / /10 30 D / / / / / / /10 50 MA300 Size 8xl0 MA300 Size 8xl / /4 75 D APOM Other / /10 90 CM Kvp Time MAS View / / /10 20 MA300 Sizel4xl7 MA300 Sizel4x17 D D 02/15 30 CM Kvp D Lateral Lumbar D A-Plumbar D /20 40 MAS MA CM Kvp Time MAS CM Kvp Time MAS / / / Size / /10 50 MA300 Size 8xl / / / D 02/ / /4 120 Ntes: D 03/ / / / DI / DI 1/ / /5 MA200 Size 14xl DI /2 CA Initials: 02 MA300 Size 14x17 75
7 FAMIL Y HEALTH HISTORY THIS FORM IS TO ASSIST THE DOCTORS BY PROVIDING PAST HEALTH HISTORY INFORMATION FOR THEIR REVIEW. PLEASE PRINT YOUR NAME HERE CONDITION SPOUSE SON DAUGHTER MOTHER FATHER ARM PAIN ARTHRITIS ASTHMA ADD/ADHD ALLERGIES BACK TROUBLE BED WETIING BACK SURGERY CANCER CARPAL TUNNEL DECEASED DIABETES DIGESTIVE PROBLEMS DISC PROBLEMS EAR INFECTIONS FIBROMYALGIA HEADACHES HEARTBURN HIGH BLOOD PRESSURE HIP PAIN LEG PAIN MENSTRUAL DISORDER MIGRAINES NECK PAIN SCOLIOSIS SHOULDER PAIN SINUS TROUBLE TMJ
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Email Address Fr cnfirming appintments, wuld yu prefer? EMAIL r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single
Reach Chiropractic Health Profile
Reach Chirpractic Health Prfile NameDate / / Age Male/Female Address City State Zip Phne: Hme Cell Cell Phne Prvider Date f Birth / / Email Address_ OccupatinEmplyer s Name Single/Married/Divrced/Widwed
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
When&did&& this&episode&start?&
GreaterLifeChirpracticHealthPrfile NameDate / / Age Male/Female Address City State Zip Phne:Hme Cell CellPhnePrvider DatefBirth / / EmailAddress_ OccupatinEmplyer sname Single/Married/Divrced/Widwed Spuse
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
LIST YOUR HEALTH CONCERNS BELOW
8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
LIST YOUR HEALTH CONCERNS BELOW
LOCATION COMING SOON Lakewood Ranch, FL 32402 941.877.1507 Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name Position Single
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
List the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
Health for Life Chiropractic At Cloverdale Mall Unit # The East Mall Etobicoke, ON, M9B 3Y
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New Practice Member Forms
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Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
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Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
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SPARROW FAMILY CHIROPRACTIC
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Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
Patient Name: Date: Address City/State Zip Code. Home. Phone Cell: Work.
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by:
New Practice Member Application
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Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
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Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
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Patient Information Packet Date:
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Patient Name Date of Birth. Address. City State Zip. Cell Phone Work Phone Home Phone . SSN Employer Name Employer Number.
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Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
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Child (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer
Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
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