• APPLICATION FOR CARE AT SPIERS CHIROPRACTIC CENTER

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  • PATIENT DEMOGRAPHICS

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  • History of complaint

    Please identify the condition(s) that brought you to this office

  • On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by selecting the number

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  • PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms:

    R = Radiating,  B = Burning,  D = Dull,  A = Aching,  N = Numbness,  S = Sharp/Stabbing,  T = Tingling

  • PAST HISTORY

  • Rows
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  • SOCIAL HISTORY

  • 2) Alcoholic Beverage: consumption occurs

  • 3) Recreational Drug use

  • FAMILY HISTORY

  • I hereby authorize payment to be made directly to Spiers Chiropractic Center, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Spiers Chiropractic Center for any and all services I receive at this office.

  • Clear
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  • By providing a telephone number and checking 'Opt-in to Text Messages', I consent to be contacted via SMS for customer care, account notifications, and delivery updates. Reply STOP to opt-out. Reply HELP for more info. Message frequency varies. Message & data rates may apply. I agree to the Privacy Policy and Terms and Conditions of Spiers Chiropractic Center.

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