youkerchiro.com - New Patient Registration Form

Dr. Steven S. Youker

3825 East State Road 64, Suite 200
Bradenton, FL 34208
Phone: (941) 750-6200
CONFIDENTIAL PATIENT INFORMATION
First Name & Last Name:

First NameLast Name
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:

MaleFemale
Age:
Date of Birth:

MonthDayYear
Date
Height:
Weight:
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
S.S #:
Occupation:
Employer:
Marital Status:

SingleMarriedWidowedDivorced
Number of Children:
ls the patient a minor?

YESNO
Spouse's Name:
Employer:
Emergency Contact:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Method Of Payment:

Cash/CheckCredit/Debit CardHealth InsuranceAuto InsuranceWorkers' Comp
ACCIDENT INFORMATION
ls Your Condition Due To An Accident?

YESNO
Type Of Accident:

AUTOWORKOTHER
Date Of Accident:

MonthDayYear
Date
Date Symptoms First Appeared:

MonthDayYear
Date
Days Lost From Work:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Do you have an Attorney?

YesNo
If yes, Name of Attorney
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE INFORMATION
Insured's Name:
lns. Co. Name:
Relation To Insured:

SELFSPOUSECHILDOTHER
Policy #:
Group #:
Claim # (lf Accident):
Adjustor Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Payment is due at the time service is rendered, unless prior arrangements have been made. I understand that I am personally responsible for payment of all services rendered to me, and agree that health and accident insurance policies are an arrangement between my insurance company and myself-NOT between my insurance company and this office. I authorize YOUKER CHIROPRACTIC to release any medical information and to complete any usual and customary reports and forms to assist in collecting from my insurance company. I know that I am responsible for my deductible, co-pays and any percentage that my insurance company does not pay for. Additionally, if the patient is a minor, I authorize treatment.
Signature: (Patient, Parent, Legal Guardian or Responsible Party)
Date:

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL PATIENT INFORMATION

ACCIDENT INFORMATION

INSURANCE INFORMATION