Honey Brook Family Chiropractic Center

INFORMATION / APPLICATION FOR CARE

The following information is needed in order to better serve you. Please complete all questions. If you need help please ask the receptionist. PLEASE PRINT.
Today's Date  
Name Email
Home Phone
Work Phone
Cell Phone
 
Address
City
State
Zip
 
Age
¬†Birth Date
Marital Status: SMWD No. of Children
 
 
Your Employer
Occupation
Years on Job
 
 
Employer Address
City
State
Zip
 
Insurance Company
     Your SS#
   
 
Do you have Medicare?     Yes
No
        Medicaid?   Yes
No
 
Spouse Name
Birth Date
   
 
Spouse Employed by
City
State
Zip
 
Work No
Does Spouse have health insurance?   Yes
  No
 
 
COMPLETE THESE DIAGRAMS
If you are in pain, please mark the exact location of your pain on the diagram. Also describe the type and frequency of your pain, as well as any activity which brings on or aggravates the pain. For example, dull, sharp, consistent, off and on, when standing, when sitting, etc.

MAJOR COMPLAINTS

Please list any condition you are being treated for or experiencing.
   

Referred to our office by

How payment will be made: Type of Insurance:
Cash Check Credit Card
Workmen's Comp.  Health Insurance Auto Ins. Po.
Is your condition due to an accident? Yes; No Date of Accident
Type of accident? Auto World On Job At Home Other
Have you ever been in an Auto Accident? Past Year Over 5 years Never
I (We) agree to pay for services rendered to the above mentioned patient as the charge is incurred. I understand and agree that health Sc accident insurance policies are an arrangement between an insurance carrier and myself and that I am personally responsible for payment of any and all services covered or not covered. I also understand that if! suspend or terminate my care and treatment, any fee for professional services rendered me will be immediately due and payable.
Patients Signature Date Or
Guardian Signature Date
Notice to our new patients: Full payment for services rendered is due at the end of each visit. If for any reason this request cannot be met, arrangements should be made in advance before seeing the doctor. Insurance Cases: On all insurance assignments the deductible should be met in the begimiing unless prior arrangements are made.