Patient Registration Form Chiropractic, Massage, Trigger Point Therapy, Salt Cave and more!Let us help you achieve your health goals! BOOK AN APPOINTMENT Leave this field blank Welcome to Our Office! 1. About Us Today's Date: File #: D.O.B Age SS #: Gender Male Female Marital Status Choose Single Married Divorced Separated Widowed Spouse's Name Do you have any children? Choose Yes No How Many? 2. Insurance Information Insured's D.O.B NOTE: Please inform the front desk if you have second source of insurance. 3. Reason For Visit The reason for this visit is a result of Auto Accident Chronic Illness or Pain Sports Trauma Work Is this condition getting worse? Yes No Is this condition: Constant Comes and goes Is this condition interfering with any of the following: Work Daily Routine Sleep Have you had this or similar condition is the past? No Yes Please explain why: Have you seen a Medical Doctor for this condition? No Yes By whom 4. In Event of Emergency 5. Health History Do you have or have you had any of the following diseases or conditions? Arthritis Lower Back Problems Artificial Bones/Joints Chemotherapy Diabetes/Tuberculosis Difficulty Breathing Asthma Fainting/Seizures/Epilepsy Sinus Problem Ulcers/Colitis Severe/Frequent Headaches Kidney Problems Rheumatic Fever High/Low Blood Sugar Psychiatric Problems Anemia Frequent Neck Pain Emphysema/Glaucoma Cancer HIV/AIDS Shingles Hepatitis Alcohol/Drug Abuse Venereal Disease Artificial Valves Congenital Heart Defect Mitral Valve Prolapse Heart Murmur Heart Attack/Stroke Heart Surgery/Pacemaker Are you taking any of the following medications? Blood Thinners Muscle Relaxers Tranquilizers Insulin Pain Killers (including aspirin) Others Supplements/Vitamins Yes No Do you exercise? Yes No How many hours/day/week: Special Diet? Yes No Do you smoke? Yes No How much do you smoke? How long have you smoked? What is the age of you mattress? Is it comfortable? Yes No For Women Patients Only: Birth Control Pills Yes No Pregnant? Yes No How many weeks Nursing a Baby? Yes No 6. Account Information Payment Method Cash Check Credit Card Visa M/C Amer, Exp. Other Card # Exp, Date I hereby authorize assignment of my insurance rights and benifits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid for by my insurance company. 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. Signature Start Drawing Clear Done Start Over Date Send
