"Patient Intake Form - Lagrange Clinic of Chiropractic"

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LaGrange Clinic of Chiropractic
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 __________________________________ Home Phone ______________ Work Phone ______________
Cell Phone _____________________ E-Mail Address _____________________________________________
Address ________________________________ City ___________________ State ________ Zip __________
Age _____ Birth date ______________________ Marital Status: S M W D
Number of Children _____
Please circle one payment type:
Cash
Check
Master Card/Visa
American Express
Your Employer ______________________________ Occupation ____________________ Years On Job ____
Employer Address _____________________________ City _____________________ State _____ Zip ______
Insurance Company ___________________________________ Your Social Security # ___________________
Do you have Medicare?
Yes ____ No ____
Name of Spouse or Parent ___________________________________
Their Birthdate _______________
Spouse Employed By ____________________________ Occupation __________________Years On Job ____
Employer Address ______________________________ City ____________________ State _____ Zip ______
Office Phone # __________________ Spouse’s SS# ___________________ Driver’s License # ____________
Does your spouse have health insurance at work? Yes ___ No ___ Spouse DOB (insurance purposes)_______
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 & on, when
standing, when sitting, etc………
MAJOR COMPLAINTS
(Please list any condition you are being treated for or
are experiencing.)
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Is your condition due to an accident?
Yes _____ No _____
Date of accident? ____________________
Type of accident?
Auto _____
Work/On Job _____
At Home _____
Other _____________________
Have you ever been in an auto accident? Past Year ____ Past 5 Years ____ 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 & 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 I suspend or
terminate my care and treatment, any fee for professional services rendered me will be immediately due and payable.
Patient’s 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 beginning unless prior arrangements
are made.
In
Case of Emergency: ( Name of relative or close friend not living in your home):
Name_______________________________________ Address______________________________________
Phone_______________________
LaGrange Clinic of Chiropractic
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 __________________________________ Home Phone ______________ Work Phone ______________
Cell Phone _____________________ E-Mail Address _____________________________________________
Address ________________________________ City ___________________ State ________ Zip __________
Age _____ Birth date ______________________ Marital Status: S M W D
Number of Children _____
Please circle one payment type:
Cash
Check
Master Card/Visa
American Express
Your Employer ______________________________ Occupation ____________________ Years On Job ____
Employer Address _____________________________ City _____________________ State _____ Zip ______
Insurance Company ___________________________________ Your Social Security # ___________________
Do you have Medicare?
Yes ____ No ____
Name of Spouse or Parent ___________________________________
Their Birthdate _______________
Spouse Employed By ____________________________ Occupation __________________Years On Job ____
Employer Address ______________________________ City ____________________ State _____ Zip ______
Office Phone # __________________ Spouse’s SS# ___________________ Driver’s License # ____________
Does your spouse have health insurance at work? Yes ___ No ___ Spouse DOB (insurance purposes)_______
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 & on, when
standing, when sitting, etc………
MAJOR COMPLAINTS
(Please list any condition you are being treated for or
are experiencing.)
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Is your condition due to an accident?
Yes _____ No _____
Date of accident? ____________________
Type of accident?
Auto _____
Work/On Job _____
At Home _____
Other _____________________
Have you ever been in an auto accident? Past Year ____ Past 5 Years ____ 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 & 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 I suspend or
terminate my care and treatment, any fee for professional services rendered me will be immediately due and payable.
Patient’s 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 beginning unless prior arrangements
are made.
In
Case of Emergency: ( Name of relative or close friend not living in your home):
Name_______________________________________ Address______________________________________
Phone_______________________