FULL NAME (as shown on insurance card)  ________________________________________________ 

ADDRESS _______________________________________     E-MAIL ADDRESS _________________

CITY, STATE_________________________  ZIP ___________       S.S. # ________________________

HOME PHONE  #  __________________________     WORK  PHONE  # _________________________

CELL PHONE #_________________________________

EMPLOYER  _____________________________     OCCUPATION   ____________________________

BIRTHDAY ______________________________     REFERRED  BY  ___________________________

SPOUSE'S  NAME ___________________________      SPOUSE'S  EMPLOYER ____________________

SPOUSE'S  BIRTHDAY _______________________     SPOUSE'S  S.S.  # _________________________

METHOD  OF  PAYMENT:  (PLEASE  CIRCLE)

CASH                         CHECK                     CREDIT  CARD                     HEALTHCARE  CREDIT  CARD

NAME  OF  PERSON  RESPONSIBLE  FOR  PAYMENT ___________________________________________

IN CASE OF EMERGENCY NOTIFY: _______________________________ PHONE # _________________

  I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this chiropractic office will be credited to my account on receipt. However, I clearly understand that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. Original X-rays will remain the property of this office and a fee may be charged for copies of X-rays. A 1.5% interest rate per month plus collection fees and attorney fees will be added to any account 90 days past due. There may be a fee charged for missing three appointments without any notice.

 I consent to any physical examination, X-ray study, laboratory procedures, chiropractic or adjunctive therapy, or clinic service that is ordered under the general and specific instructions of the doctor(s). I also understand that the doctor will not likely be able to adjust my spine on the first visit. I also consent to signing in on a patient roster that is placed on the waiting room counter. All patients sign this sign-in form and it is possible that other patients may view your name.

 I will pay for services rendered on that day unless other arrangements are made prior to the office visit. I certify that the above information is correct to the best of my knowledge. If you have any questions or concerns about these details please discuss them with the doctor and/or staff.


PATIENT'S  SIGNATURE _________________________________________   DATE _______________


INFORMATION  TAKEN  BY: ______________________________________  DATE _______________


RELATIONSHIP TO PATIENT ___________________________