First Middle Last
Address ________________________________ City __________________ State __ Zip _______
Home Phone _____________ Work Phone ______________ Sex Male Female
Date of Birth __________________ Marital Status: M S D W
Spouses Name ________________ Work Place _____________________ Work Phone _________
Your Employer _________________________________ Occupation _______________________
Person to contact in case of emergency ____________________________ Phone ______________
Whom may we thank for referring you to us? ___________________________________________
Name of person responsible for this account ___________________________________________
Relationship to patient _____________________________ Phone # ________________________
Address ______________________________ City ______________________ State __ Zip _____
Employer ________________________________________ Work Phone ____________________
Primary Insurance
Name of insured _______________________________ Relationship to patient _______________
Date of Birth _______________ SSN _____-____-_____ Date Employed ____________________
Name of Employer ________________________________ Work Phone ____________________
Address _____________________________ City __________________ State __ Zip __________
Insurance Co ______________________ Phone # ________ Group # _______ Employer #______
Address _____________________________ City __________________ State ____ Zip ________
Secondary Insurance
Name of insured ____________________________ Relationship to patient __________________
Date of Birth _______________ SSN _____-____-_____ Date Employed __________________
Name of Employer _________________________ Work Phone ____________________
Address __________________________ City __________________ State __ Zip _____
Insurance Co ______________________ Phone # __________ Group # _____________
Address __________________________ City __________________ State __ Zip _____
I certify that I have read and understand the above information to the best of my knowledge. I authorize the chiropractor to release any information including diagnosis and records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractor insurance benefits otherwise payable to me. I understand that my chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents as provided for in any provider agreement between the doctor and your insurance company, if any exists.
Signature of Patient (or parent if a minor) Date