Please fill out the form completely

For exercise you
You drink oz. of water/day. You drink cups of coffee or soda/day. You drink alcoholic beverages/day.
You take these vitamins every day
You take these drugs every day for this condition:
                                                         for this condition:
                                                         for this condition:
Who may we thank for referring you to our office?
Payment is expected at the time of your visit. Please indicate your preferred method of payment

                                                 CASH CHECK VISA MASTERCARD ATM

INSURANCE INFORMATION

PRIMARY
Carrier Name of Insured
Birthday of Insured Insured of SSN
Your relationship to insured SPOUSE CHILD SELF OTHER

SECONDARY
Carrier Name of Insured
Birthday of Insured Insured of SSN
Your relationship to insured SPOUSE CHILD SELF OTHER

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