Chiro Forms by Binary Ideas AI Agency

Patient Information

Date Today

SS/HIC/Patient ID #^*

Patient's Name

Last Name

First Name

Middle Initial

Address

Address 1

City

State

Zip

Sex

Date of Birth

Age

Civil Status

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse' BirthDate

SS #

Spouse's Employer

Whom we may thank for referring you?

Insurance

Who is responsible for this account?^*

Relationship to Patient^*

Insurance Co.^*

Subscriber/Member id #^*

Group #^*

Is patient covered by additional insurance?^*

Yes

Subscriber's Name

BirthDate

SS #

Relationship to Patient

Insurance Co.

Group #

Assignment and Release

I certify that I, and/or my department(s), have insurance coverage with

And assign directly to Dr.

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian, or Personal Representative^*

Please print the name of Patient, Parent, Guardian, or Personal Representative

Date

Relationship to Patient

Phone Number

Home Phone^*

Cell phone^*

Best time and place to reach you

In case of emergency, contact:

Name

Relationship

Home Phone

Work Phone

List all medications you are currently taking

Medicine

Pharmacy Name

Pharmacy Phone

List all allergies you currently have

List all vitamins you are currently taking

Name

Patient Information

Insurance

Phone Number

Accident Information

Patient Condition

Health History