PATIENT INTAKE FORM
PLEASE FILL OUT THE BELOW FORM COMPLETELY - THANK YOU!
Name
*
First Name
Last Name
Date Of Birth
*
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Month
-
Day
Year
Sex
*
Please Select
Male
Female
Other
Rather Not Say
Full Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Phone Number
*
Format: (000) 000-0000.
Email
*
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Rather Not Say
Occupation
*
Reason for visit
*
Do you take any medications? If so, list medications
If injured, is this injury related to:
Please Select
Auto Accident
Slip & Fall
Work Related
Sports
Other
Has injury been treated before?
Please Select
Yes
No
What treatment was performed or recommend?
Who or where was the treatment performed?
Is injury getting progressively worse?
Please Select
Yes
No
Location of injury/pain
Please Select
Head
Neck
Shoulder
Back
Arm
Hand
Elbow
Hip
Thigh
Knee
Leg
Ankle
Foot
Symptoms of injury/pain
Please Select
Achy
Burning
Numbness
Pins & Needles
Stabbing
Tightness
What is your level of pain?
1 - Very Little
2
3
4
5 - Moderate
6
7
8
9
10 - Severe
I would like to receive marketing texts/emails as well as appointment reminders
*
Please Select
Yes
No
How did you hear about us or who referred you?
*
Google
Social Media
Other Advertising
Insurance
Existing Patient
Attorney
Doctor
Other
Signature of Responsible Party (Patient or Parent): Our office will provide insurance billing services for you if you so desire as a courtesy. Remember you are ultimately responsible for any charges incurred in this office. It is your responsibility to pay any deductible amount, co-insurance and or any other balances not paid by your insurance carrier. Your signature on this document indicates that you agree to pay for any outstanding bills incurred in this office.
Todays Date
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Month
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Day
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