Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
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1 Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability. Patient Information Title: Mr. Mrs. Miss Ms. Dr. (circle one) DATE Last Name First Middle Initial Address City State Zip Phone: Home Work Cell Gender: MALE FEMALE Birthdate Social Security # Status: Married Single Widowed Divorced Child Other Spouse s Name Children s names How were you referred to this office? (circle all that apply) Yellow pages Newspaper Flyer Radio TV Friend/ Relative (Name ) Other Your occupation Employer Employer s address City State Zip Nearest Relative not living with you Relative s phone Address City State Zip Other doctors seen for this condition? MD DC DO DDS Doctor s name Diagnosis X-rays? YES NO Length of time under care Off work? YES NO If yes, how long? Have you returned to the same job? YES NO Treatment received: Medication Physiotherapy Adjustments Surgery Other Results Ever seen another chiropractor/dc? YES NO Name Date(s) Height Weight Blood pressure Smoking status: (circle one) Current every day, current some days, former smoker, never smoker Race: (Circle one) African American, American Indian, Asian, Black, Native Hawaiian, Pacific Islander, White, decline, Unknown Ethnicity: (Circle one) Hispanic/Latino, Not Hispanic/Latino Insurance Information Are you covered under any group, union, or personal health and accident insurance? YES NO Insurance company Major policy holder Relation to policy holder Policy or contract #
2 PLEASE ANSWER THOROUGHLY FOR BEST EVALUATION Primary area of discomfort How long have you had this condition? Days Weeks Months Years As far as you know, the cause was If condition is due to any injury, what day did the injury occur? Place injury occurred: ( ) Home ( ) Work ( ) Other Intensity of discomfort: ( ) Mild ( ) Moderate ( ) Severe Frequency of discomfort: ( ) Constant ( ) Daily ( ) Intermittent times per Day / Week How would you describe the pain: ( ) Sharp ( ) Dull ( ) Achy ( ) Stiff ( ) Throbbing ( ) Tingling Other Pain is getting: ( ) Better ( ) Worse ( ) Staying the same What aggravates the discomfort: ( ) Lifting ( ) Bending ( ) Lying ( ) Sitting ( ) Walking ( ) Standing Other Time of day discomfort is most noticeable: ( )Morning ( )Afternoon ( )Evening ( )Increases during day Discomfort decreased when/with: ( )Resting ( )Lying ( )Sitting ( )Standing ( )Ice ( ) Heat ( )Other Names of other doctors seen for this condition? I have tried: ( )Aspirin ( ) Muscle Relaxers ( ) Pain Medication ( )Cortisone ( )Other Results Have you had any surgical operations? ( ) Yes ( ) No What kind? Are you taking any prescription medication? What kind? Are you allergic to any prescription medication? PLEASE NOTE THE LOCATION OF YOUR DISCOMFORT Headaches Neck Pain Back of head Left side Right Side Both sides Top of head Side(s) of head Pain travels to: Front of head Upper back Left Right Behind the eyes Shoulders Left Right Other Arms Left Right Hands Left Right Fingers Left Right Other Low Back Pain Left side Right side Both sides Mid Back Pain Left side Right side Both sides Pain travels to: Legs Left Right Pain travels to: Buttocks Left Right Neck Left Right Thighs Left Right Shoulders Left Right Left Right Arms Left Right Knees Left Right Around Rib Cage Left Right Ankles Left Right Through chest Left Right Feet Left Right Other Other Other areas of discomfort:
3 Other health issues: I hereby authorize the Doctor to care for me as he deems appropriate. I will not hold him responsible for any pre-existing medically diagnosed condition(s), nor any medical diagnosis. The information I have given is accurate and true. SIGNATURE DATE Professional fee Schedule Our experience has shown that it is wise to have an understanding with our patients regarding our office policies and fees. We offer several methods of payment for your chiropractic care and you have chosen to bill your health insurance. The information you provide will enable us to best serve you and to help avoid misunderstandings in the future. Our main concern is your health and well-being. The fees that follow are general. Your specific plan will dictate your individual charges. Consultation No Charge Chiropractic Examinations $40 - $140 Spinal Adjustment (1 to 5 areas) $60 - $70 Extremity Adjustment $40 Manual Therapies $40 - $115 Chiropractic X-ray studies $65 - $365 Patient / Doctor Conference $40 - $70 Plan # 4 GENERAL HEALTH INSURANCE If you have insurance which covers chiropractic care, we will bill your insurance company directly and handle requests for information and documentation. We will make a copy of your insurance card and verify coverage for you. You will be responsible for your deductible and co-pay or the monthly co-pay arranged for you. Signature Date 9/23/09
4 Explanation of professional Fees Consultation: No charge The consultation takes place subsequent to the New Patient Examination. The Doctor will discuss with the patient any current complaints. The Doctor will also give the patient a brief explanation of Chiropractic and the care they will be receiving. New Patient Examination: $50-$140 The Doctor will review the Patient History form describing the patient s chief complaints. At that time, a postural exam, range of motion study, and any necessary orthopedic tests will be performed. Established Patient Examination: $40-$60 Periodically the Doctor will monitor percent improvement and will obtain additional information on a visit related to progress or aggravation from initial findings. Chiropractic Adjustment: $60-$70 Generally an adjustment will be performed each visit to address the individual s subluxation patterns. There are up to four areas of the spine that may be involved. Extremity Chiropractic Appointment: $40 Additional areas outside the spine such as knees, wrists, etc. that may require care. Manual Therapies: $ Manual therapies consist of services such as, but not limited to, lymphatic drainage, manual traction, and myofascial trigger point. Chiropractic X-ray Studies: $65-$360 Subsequent to the consultation, and after careful review of the patient s complaints. The Doctor will determine if x-rays are necessary for the proper care of the patient.
5 Patient/Doctor Conference: $40-$70 The patient/doctor conference is a specific office visit at which time the Doctor reviews with the patient their examination finding, including physical examination and X-ray examination study, lending itself to aid the patient in understanding and participating in the health findings and care. Signature Date Carefree Chiropractic 3365 N. Academy Blvd. Colorado Springs, CO FORM: NOTICE OF PRIVACY PRACTICE SUMMARY This summary discloses how health information about you may be used. A full notice of your privacy rights has also been provided to you. Carefree Chiropractic uses health information about you for treatment, to obtain payment for treatment with your authorization as required (check your state laws.), for administrative purposed, and to evaluate the quality of care that you receive, Carefree Chiropractic will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. Carefree Chiropractic may use your information to provide appointment reminders, information about treatment alternatives or other health-related issues. Carefree Chiropractic may disclose your information for public health activities, to funeral directors to enable them to carry out their activities, for organ and tissue donations, research, health and safety, governmental function in order to comply with workers compensation laws and regulations, a right to request restriction, report and retain a copy of your health record, request communication of your information by alternative means at alternative locations, revoke your authorization and request an accounting of your health records. You may complain to Dr Johnson and to the Department of Health and Human Services if you believe you r privacy rights have been violated. You will not be retaliated against for filing a complaint. Carefree Chiropractic must maintain the privacy of protected health information, provide you with notice of its legal duties and privacy practices with respect to your health information, abide by the terms of the notice, notify you if it was unable to agree to the requested restriction on how your information by alternative means or by alternative locations and obtain your written authorization to
6 use or disclose your health information for reasons other than those listed above and permitted under law. If you have any questions of complaints please contact Dr. Doug Johnson at (719) Patient Signature Date
7 TERMS OF ACCEPTANCE When a patient seeks chiropractic healthcare, and when a chiropractor accepts a patient for such care, it is essential that both are seeking and working for the same goals. Chiropractic does NOT diagnose or treat disease. Chiropractic has only one Goal: TO LOCATE, ANALYZE, AND CORRECT SPINAL INTERFERENCE TO THE NERVOUS SYSTEM The purpose of the nervous system is to control and coordinate all bodily function. Interference to this master system automatically produces improper function of the body. The SUBLUXATION (spinal misalignment producing nerve interference), in and of itself, is a detriment to life and health. Correction of the subluxation through a specific chiropractic adjustment allows the body to function at its optimum level. This allows the innate healing power of the body to work at maximum efficiency to restore, maintain, and promote natural health. WE DO NOT DIAGNOSE CONDITION(S) OR DISEASE(S) OTHER THAN VERTEBRAL SUBLUXATIONS. WE OFFER NO TREATMENT OF CONDITION(S) OR DISEASE(S) OTHER THAN VERTEBRAL SUBLUXATIONS. WE PROMISE NO CURE FROM ANY CONDITION(S) OR DISEASE(S). THE CHIROPRACTIC ADJUSTMENT RESTORES LIFE AND HEALTH TO ITS FULLEST POTENTIAL! I,, having read the above statements, and understanding them fully, do undertake chiropractic health care on this basis. Date: Signature:
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
Welcome to Manna Family Chiropractic!
Welcome to Manna Family Chiropractic! Today s date Who should we thank for referring you here? Is your visit today regarding you, or your whole family? Family Just Me Your name Date of Birth Street Address
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
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
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
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
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
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
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Chiropractic Health Dr. Art Vanderhoef
Patient Information Form Chiropractic Health Dr. Art Vanderhoef File # Name Address City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email Address How do you prefer to be contacted? Mail Home
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Last Name First Name M.I Nickname Address City State Zip_. Date of Birth Age Gender: M F Marital Status: S M W D INJURY INFORMATION
PATIENT REGISTRATION Date: Last Name First Name M.I Nickname Address City State Zip_ Mobile Phone Home Phone Work Phone E-Mail SSN Date of Birth Age Gender: M F Marital Status: S M W D Employer Name Occupation_
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
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 /
Notto Chiropractic Health Center Patient Information
Notto Chiropractic Health Center Patient Information Acct #: Name: Preferred Name: Address: City: State: Zip: Home Phone: ( ) - _. Work Phone: ( ) -. Who Referred You? In Case of Emergency: Phone Number:
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 /
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
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
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.
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
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
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
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
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
PERSONAL INJURY VERIFICATION
PERSONAL INJURY VERIFICATION Name Email Home Phone Cell Phone Address City Zip Code Birth Date Age Marital Status Employer Occupation Name of Spouse In case of emergency, please notify Phone MED-PAY Policy
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
Welcome to our Family Chiropractic Office
Welcome to our Family Chiropractic Office Thank you for choosing our office for chiropractic care. We are committed to providing your family with the highest quality of corrective and wellness chiropractic
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
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
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
Luker Chiropractic Health Questionnaire
Luker Chiropractic Health Questionnaire Name: D.O.B.: Address: City: State: Zip: Home Phone: Cell: Email: Male/Female Marital Status: M W D S Age: SS# Occupation: Employer: Spouse Name: # of Children:
A Total Wellness Center
800 Hwy 290 W./Building F Dripping Springs, TX 78620 (512)-858-9355 www.ffchiro.com Welcome To Family First Chiropractic! Welcome to our office! Rest assured that you will be provided the most appropriate
Registration and History Form
Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
Natural Health Center
Natural Health Center 420 Yucca Lane - Turpin, OK 73950 Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340 Today s Date / / Application for Treatment Name: Birthdate: SS# Address:
AUERBACH CHIROPRACTIC
AUERBACH CHIROPRACTIC ARTS AND SCIENCE Dr. Gary Auerbach 2730 N. Pantano Road Tucson, AZ 85715 Phone: 520-721-7177 Welcome to the office of Auerbach Chiropractic Arts and Science. In order to better serve
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:
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
PATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
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
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
FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
3330 South Price Road, Suite D-110 Tempe, Arizona 85282 Phone: 480.345.2080 Fax: 480.345.2199 W E L C O M E ABOUT YOU (please print) Today s Date: Patient Name: DOB: Age: SS#: Mailing Address: City: State:
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
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
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
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
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
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
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
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
Chiropractic Sports & Wellness PC New Patient Questionnaire
Chiropractic Sports & Wellness PC New Patient Questionnaire Dr. Paul R. Cassista & Dr. Kayla J. Madler Patient Information (Please Print) Please provide a copy of your card & a photo id to the front desk
Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status
Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
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 REGISTRATION FORM
PATIENT REGISTRATION FORM (Please print clearly) Last Name MI First Name Date of Birth Home Address Mailing Address if different Home Phone Work Phone Other/Cell Phone EHR Certification Patient Information
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
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
Patient Information Name: First Last M.I. Date: Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Email: Phone: Cell/Home/Work (please circle one) How did you hear about us? Door hanger, Fargo
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
CHIROCENTER. Home Address: City: State: Zip: I would like to receive notifications Please do not send notifications
CHIROCENTER PATIENT ADMITTANCE Name: (First) (Middle Int). (Last) Today s : Home City: State: Zip: Telephone: Work: Cell: of Birth: Sex: M or F Social Security#: (Month) (Day) (Year) Circle if you are:
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM NAME: D.O.B AGE: SEX: STREET: CITY: STATE: ZIP: SS #: ETHNICITY: RACE: LANGUAGE: PHONE # TO LEAVE A PERSONAL MESSAGE: HOME PHONE #: WORK #: CELL #: E MAIL ADDRESS: EMERGENCY CONTACT:
Welcome to our Office!
Welcome to our Office! Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don t hesitate to ask one of our qualified team members. It is our pleasure
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
Physical Evidence Chiropractic 7035 Beracasa Way Suite 103 Boca Raton FL, Phone# (561) Fax# (561)
7035 Beracasa Way Suite 103 Boca Raton FL, 33433 Phone# (561)361-4888 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name Address City State Zip Date of Birth Age Social Security # Circle
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address
PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
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:
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
INTRODUCTION PATIENT CASE HISTORY
INTRODUCTION PATIENT CASE HISTORY Today s Date: / / PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #: Home: Mobile:
General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
General Information: First Name: Middle Initial: Last Name: Suffix: Called Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: Marital Status:
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
WELCOME! All our best, Dr. Christopher and Lily Bargmann
WELCOME! We are so glad you re here. Our focus is to help restore normal, healthy function to each of our patients bodies, hopefully allowing them to live a longer, fuller life. Some people are looking
Sincerely, Dr. Justin & Woodbury Spine Staff
Welcome to our office! We are sure that you will be provided the most appropriate and professional chiropractic care possible. Our most important goal is the constant improvement and maintenance of your
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
Solecki Chiropractic Case History
Solecki Chiropractic Case History Date: Pa ient #_ octor: Name: Social Security #: Age: Birth Date: Marital: Address: City: State: Zip: E-mail address: Home Phone: Cell Phone: Contact Preference: Hm PH
Patient Application Form
Patient Application Form Welcome to our clinic. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural correction programs. Our approach is very
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT Patient (First) (Middle) (Last) Address City State Zip E-mail address Home Phone # Cell Phone # Would you like an appointment reminder? Text( ) Call(
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency
Patient Health Questionnaire
Patient Health Questionnaire Demographics Patient Title (check one): Mr. Mrs. Miss Dr. Prof. Rev First Name: Middle Name: Last Name: Suffix: Address: City: State: Zip Code: Date of birth: Age: Cell Phone:
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
Dr. Brett Whitekettle
Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
New Member Contact Information
New Member Contact Information Date: Social Security #: - - File Number: First Name: Middle Initial: Last Name: Age: Birth Date: / / Gender: M F Marital Status: S M D W Home Address: Home Phone: - - City,