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New Patient Welcome Packet

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New Patient Welcome Packet

  1. 1. Welcome...We are glad you’re here!Please describe your major complaint ______________________________________________________________________________________________________________________________________________Was this problem due to _____ Auto accident — Date: _________________ _____ Work accident — Date: ________________ _____ OtherWhen noticed (if accident or injury please describe) __________________________________________________________________________________________________________________________________How does this interfere with normal living? _______________________________________________________________________________________________________________________________________What activities make it worse? _________________________________________________________________________________________________________________________________________________Have you had treatment for same or similar condition? ______________________________________________________________________________________________________________________________What have you done to treat this condition? ________________________________________________________________________________________________________________________________________Please List: 1. Past Injuries ______________________________________________________________ 2. Auto Accidents ___________________________________________________________ 3. Major Illness (include year/type)______________________________________________ ________________________________________________________________________ 4. Operations/Surgery (include year/type) ________________________________________ ________________________________________________________________________ 5. Other doctors seen (and for what condition) _____________________________________ ________________________________________________________________________ ________________________________________________________________________Are you taking any medication (and for what)? ______________________________________________________________________________________________________________________________________Any known Allergies to Medications?_____________________________________________________________________________________________________________________________________________Do you some or use tobacco? ______________________________Have you been diagnosed or treated for Hypertension (high blood pressure)? Yes: _____ No: _____Previous chiropractic care (Dr. name and date of last visit)? ____________________________________________________________________________________________________________________________
  2. 2. Name ______________________________________________ Date ________________________________Address _______________________________________ City____________ State ____ Zip _____________Social Security Number _____________________________ Birth Date __________________ Age ________Phone (home) ________________ (cell) _________________ Cell Phone Company _____________________ (to text reminders)Primary Language Spoken: ________________ Race: _______ Ethnicity: Non-Hispanic: __ Hispanic: __ Other ___Sex: M F Marital Status: M S W D Sep Email address ____________________________________________Employer __________________________ Occupation ____________________ Work Phone ____________Spouse Name ____________________________________ Number of Children _______________________Who may we thank for referring you? __________________________________________________________Name of your Medical Doctor ________________________________________________________________Name of emergency contact person: ____________________________ Relation: ______________________Address _________________________________________________ Phone __________________________Employer _______________________________________________ Phone __________________________  It is your responsibility to notify us when you have a change in your insurance informationInsurance Information: Please present your insurance card to be copied for our records.Supplemental Insurance ? __________________________________________________________________________Personal Injury/Auto Accident Name/Address of Company __________________________________ Claim # _________________________ Adjuster’s Name ___________________________________ Is an attorney representing you in this case? Y N Name of Attorney ___________________________________ Phone _______________________________Other name and Address of Company _____________________________________________________ ID &/or group # ____________________________________________________________________I certify that the above information is true and correct. I hereby authorize the release of any information required. I also author-ize my benefit payments to be paid directly to this office. I am financially responsible for non-covered services. If accepted as apatient at Patrick Chiropractic, I authorize any treatment which may be necessary. Any risks regarding Chiropractic Care will beexplained upon my request.Fees are due at the time service is rendered.I plan to pay be: _________ Cash ___________ Check ______________ Credit/Debit CardDate ______________________________ Patient/Guardian Signature _______________________________

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