DATE: _______________________

LAST NAME: ______________________ FIRST _________________________ MI.___________

ADDRESS: ______________________________________________________________________
CITY___________________________________ STATE: ________ ZIP: ____________________
HOME PHONE: ________________ WORK: _________________ CELL: _________________
SEX: M / F ______ MARRIED/ SINGLE DOB: ______________ SSN: ____________________
EMPLOYER: ____________________________________________________________________
E-MAIL : ________________________________________________________________________
SPOUSES NAME: _____________________________ SPOUSE DOB: _____________________
SPOUSES EMPLOYER: ___________________________________________________________
*Is this consultation due to an AUTO ACCIDENT or WORKERS COMPENSATION? YES____
If yes which one? ____________ What was the DATE OF THE INCIDENT? _____________

NO____

**How were you referred to us?_________________________________________

BILLING INFORMATION
_____ I have no insurance coverage and I understand that I will be responsible for my account. I also
understand that payment is expected at time of service.
Name of Primary Ins. Company: ____________________________________________________
Name of Insured: _____________________________ Insured DOB: ________________
Policy #: ____________________________________ Group: _____________________
Relationship to Insured: Self____ Spouse____ Child____
Name of Sec. Ins. Company: ____________________________________________________
Name of Insured: _____________________________ Insured DOB: ________________
Policy #: ____________________________________ Group: _____________________
Relationship to Insured: Self____ Spouse____ Child____
* Please be advised that it is your responsibility to pay any additional costs not covered by your Insurance
Company.
I hereby state that all the information given is complete and correct to the best of my knowledge.
________________________________________
SIGNATURE

____________________
DATE

No minor will be treated unless this form is signed by a legal guardian.

I hereby authorize the doctors and whomever they designate as their assignment, to administer treatment as they
so deem necessary to my child.
________________________________________
SIGNATURE
NEW PT. FORM

____________________
DATE

WON,TAN OI\L\.
ls lhere a confirmed or suspected pregnanc\, at tfus time? \/FQ \In
r'\,,o UdtC.
Tr,.e-,.
1\V
LU!
r'*if vr:r: brlcoile pregnart or suspect a
irregsancy at any trme during the course oj ]iour treatrrienl , please
notiiy the doctor and the therapisi.
r r rur

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atttl

t I I I a t ! ! t I r rr

I r a,r

fii

h1farli the area CIn the bod1, r,r,here

]rou feel ihe described sensafions. Tise the appropria{e

lnclude all affected areas.

s'rnbol,

Nr.unbness

l3urning xxxx

Dull Pain /,',',/

Pins

& Needls.s ocao

Stabbing +l--l-+

Er t t r

Heaf;th

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I t tr

'

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ni

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lnforruatiorr

\,{ajor CornplaiLit.
I'ypcs & darcs oi'sur.geries:
List erry iinplanteci devices :rid their locaLions
Please list any rnedications being iaken
F{ave vou had ciriropractic ca:-e before:
I

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g tl

I E ! i t i !

'

..

t I t i t t I rt

Name of previous doctt:r

I r I I

r ar

rr

r r r r tr

! !r

r I t !r

t r trt

a r a t i r a r ! tr:

['lcase cl,recli all of tl-re follolving healih svmptoms fhat

vou nray be experiencine.:

_ljeadaclies

_Neck

_Still

Pairi

l-reclL

_.Sleep Pi oblerns
-* Brcl< Pain

_Nen

ousrtess

_Tension
,*,hrirabifiry
_Clrcst Palrs
_Siroulder Pain
_Dizziness
_Fiead seeiTrs heavy
*_Pins/Needles ,{rms
Camnreiiti.

Pins.iNeedles Legs

_Numbness in Fingers
_*|'lumbness in Toes
-_Sfrorr of breath
_

_.Fatigrrr

_,Depression
_ Ffiee Pai-ir
_Lighi hufls e1,es
_Loss of memorY
_Ears ringing
Flushes

_Face
_Buzzing in ear-s
_LrrsS ,r I baiance

Fainting

_Loss of smel1
_Loss oi taste
TivlJ l?ain
_I)ian hea
_ _Feet ci:ld

_Hands cold
_Stomach upser
*_Constipation

_Cotd

sn'eats

_F{iatal hernia
_Aiiergies

Joint paiir

t r r f r i