OTHER
The next day you felt
Today your worst pain is
Have you seen your primary care or another doctor about this condition? Yes No
If yes, name of doctor in the city of
He/She recommended
You Have Have not previously had same/similar complaints. When? Month Year
Treatment for these complaints:
Medication Chiropractic Care Physical Therapy Surgery None
Other
Have you lost time from work due to this injury? Yes No Dates:
Are you able to perform your normal activities? List things you can't do:


Name of your attorney City of Phone

Other Injuries

Month Day Year Body part injured Treated? Yes No
Month Day Year Body part injured Treated? Yes No
Month Day Year Body part injured Treated? Yes No
I have never had any other injuries.

Insurance Information
Name of Insured Relationship to patient
Name of Insurance co. Street Address
City State Zip Claim No Contact
Other vehicle insurance carrier City of
Claim No. (if known)
My health insurance carrier City of

PLEASE PRESENT YOUR INSURANCE CARD/CERTIFICATE TO THE FRONT DESK FOR COPYING
PLEASE PRESENT YOUR DRIVERS LICENSE TO THE FRONT DESK FOR COPYING

We are happy to provide insurance billing for you as part of our service at no charge to you.
However, your insurance is a contract between you and your carrier. You are ultimately responsible
for all charges incurred at this office. Please sign below, acknowledging your responsibility.

____________________________________________________________________________________________
SIGNATURE OF RESPONSIBLE PARTY                                                                                                  DATE



OUR MISSION IS TO PROVIDE
CAREFULLY CONSIDERED DIAGNOSIS
GENTLY ADMINISTERED TREATMENT
THE CARE YOU NEED, NO MORE, NO LESS
REFERRAL TO OTHER PRACTITIONERS WHEN APPROPRIATE
HONEST AND UP TO DATE RECORD KEEPING...IN SHORT

TO TREAT YOU THE WAY WE WOULD LIKE TO BE TREATED IF WE WERE THE PATIENT.

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