• New Patient Registration

  • Patient Information

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Marital Status
  • Format: (000) 000-0000.
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • Insurance Information

  • Is patient covered by additional insurance?
  • Birthdate
     - -
    2 digit month, 2 digit day, 4 digit year

  • ASSIGNMENT AND RELEASE

    I certify that I, and/or my dependent(s), have insurance coverage with      and assign directly to Dr.      all insurance benefits. If any, otherwise to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

    The above named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This concept will end when my current treatment plan is completed or one year from the date signed below.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • In case of Emergency, Contact

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is condition due to an accident?
  • Date of Accident
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of accident
  • To whom have you made a report of your accident?
  • Is this condition getting progressively worse?
  • Mark an X on the picture where you continue to have pain, numbness, or tingling
  • Type of Pain
  • Does it interfere with your
  • Activities or movements that are painful to perform:
  • What treatment have you already received for your condition?
  • Name and address of other doctor(s) who have treated you for your condition
  • Last Physical Exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Dental X-ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Spinal Exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Spinal X-ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last MRI, CT-Scan, Bone Scan
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Chest X-ray
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Blood Test
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last Urine Test
     - -
    2 digit month, 2 digit day, 4 digit year

  • Place a mark on "Yes" or "No" to indicate if you have had any of the following:

  • AIDS / HIV*
  • Alcoholism*
  • Allergy Shots*
  • Anemia*
  • Anorexia*
  • Appendicitis*
  • Arthritis*
  • Asthma*
  • Bleeding Disorders*
  • Breast Lumps*
  • Bronchitis*
  • Bulimia*
  • Cancer*
  • Cataracts*
  • Chemical Dependency*
  • Chicken Pox*
  • Diabetes*
  • Emphysema*
  • Epilepsy*
  • Fractures*
  • Glaucoma*
  • Goiter*
  • Gonorrhea*
  • Gout*
  • Heart Disease*
  • Hepatitis*
  • Hernia*
  • Herniated Disk*
  • Herpes*
  • High Blood Pressure*
  • High Cholesterol*
  • Kidney Disease*
  • Liver Disease*
  • Measles*
  • Migraine Headaches*
  • Miscarriage*
  • Mononucleosis*
  • Multiple Sclerosis*
  • Mumps*
  • Osteoporosis*
  • Pacemaker*
  • Parkinson's Disease*
  • Pinched Nerve*
  • Pneumonia*
  • Polio*
  • Prostate Problem*
  • Prosthesis*
  • Psychiatric Care*
  • Rheumatoid Arthritis*
  • Rheumatic Fever*
  • Scarlet Fever*
  • Sexually Transmitted Disease*
  • Stroke*
  • Suicide Attempt*
  • Thyroid Problems*
  • Tonsilitis*
  • Tuberculosis*
  • Tumors, Growth*
  • Typhoid Fever*
  • Ulcers*
  • Vaginal Infections*
  • Whooping Cough*
  • Exercise
  • Work Activity
  • Habits
  • Injuries/Surgeries you have had
    Rows
  • Format: (000) 000-0000.
  • Should be Empty: