Patient Registration Form

Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!
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Welcome to Our Office!

1. About Us

2. Insurance Information

NOTE: Please inform the front desk if you have second source of insurance.

3. Reason For Visit

4. In Event of Emergency

5. Health History

For Women Patients Only:

6. Account Information

7. Account Information

I authorize the staff to perform any necessary services needed during diagnosis and treatment, I also authorize the provider and/or managed care organization to release any information required to process insurance claims.

I understand that payment in full, for all services rendered, is requested at the time of visit, unless or arrangements have been made beforehand with the business office. If my account is not paid within 90 days of the date of services and no financial arrangements have been made, I will be responsible for legal fees, collection agency fees, and other expenses incurred in collecting my account.

I understand the above information and guarantee, to the best of my knowledge, this form was completed correctly. I understand that it's my responsibility to inform this office of any changes to the information I have provided.