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.
Marital Status: SMWD No. of Children
Years on Job
Do you have Medicare? Yes
Spouse Employed by
Does Spouse have health insurance? Yes
COMPLETE THESE DIAGRAMS
If you are in pain, please mark the
location of your pain on the diagram. Also describe the
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.
Please list any condition you are being treated for or experiencing.
Referred to our office by
How payment will be made:
Type of Insurance:
Auto Ins. Po.
Is your condition due to an accident? Yes;
Date of Accident
Type of accident? Auto
World On Job
Have you ever been in an Auto Accident? Past Year
Over 5 years
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.
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.
On all insurance assignments the deductible should be met in the begimiing unless prior arrangements are made.