Full Name: _____________________________________prefer to be called? ______________________

Address: ____________________________City:  _________________ State: _____  Zip: ___________

Home Phone: (____)_____________Cell: (_____)____________Work Phone: (______)______________

E-Mail Address (for our newsletters): ______________________________________________________

Social Security Number: ______________________  Birth date: _____/_____/_______ Age: _________

Marital Status:   S    M    D   W     Spouse’s Name: ____________________ Occupation: _____________

Patient’s Employer/Business: ___________________________ Occupation: _______________________

Hobbies/Activities: __________________________________________________________________

Spinal health is especially important during pregnancy. Is there a chance you are pregnant? YES      NO

Have you previously been under chiropractic care?    Y    N    Date of last visit: _____/______/_________

Primary Health Insurance Company Name: _______________________________________________

Address: __________________________________________________________________________

ID #: _____________________________  Phone Number: __________________________________

(If Applicable) Secondary Health Insurance Company Name: ___________________________________

Address:_______________________________________________ID #: __________________________ Phone Number:__________________________________________

Terms Of Acceptance

OUR PRACTICE OBJECTIVE is to eliminate any major interference to the expression of the body’s innate wisdom. Our methods typically include specific adjustments, therapeutic exercises, and muscle work.

I authorize the Doctor to provide any forms of evaluation, x-rays and treatment that may be indicated in connection with the patient above, and further authorize and consent that the Doctor chooses and employs such assistance as he sees fit. I also understand that prior to care, full explanation of procedure(s) involved will be given. I agree to pay all services rendered in this office.

I authorize the release of any and all information to any insurance company, attorney, or adjuster in order to process claims for reimbursement for chiropractic charges rendered in this office.

Signature: _______________________________________   Date: ______/ _____/ ______

Relationship to Patient: _________________________________