Medical Insurance Application
Do you have Medicare insurance?
*
Yes, I have Medicare (Not accepted at this clinic)
No, My insurance is not Medicare
Name
*
Prefix
First Name
Last Name
Gender
*
Male
Female
Age
*
Patient Status
*
Single
Married
Student
Employed
Other
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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5
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30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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2002
2001
2000
1999
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1991
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number (Home)
Format: (000) 000-0000.
Phone Number (Mobile)
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Insurance Information
Coverage Type
Please Select
Self Pay
Commercial (PPO)
Insurance
Please Select
Aetna
BCBS
Cigna
United Health Care
others
Member ID
not necessary
Referred by
Front of Insurance
Browse Files
Drag and drop files here
Choose a file
Cancel
of
back of Insurance
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ID (e.g., Driver’s License, Passport, etc.)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have secondary insurance?
Yes
No
By signing below, I confirm that the information provided is accurate to the best of my knowledge. I authorize the clinic to use and disclose my health information for treatment, payment, and healthcare operations in accordance with HIPAA regulations.
Sign
*
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The Vit Healing Intake Form
NOT NECESSARY
Primary Areas of Concern & Primary Health Goals
For any primary area(s) of concern, please share with us any details about when it began, and what makes it better or worse as well as whether you have experienced these issues in the past, and when.
Do you have any related diagnosis or imaging results?
Yes
No
If you are experiencing pain in your body, please share with us any details about where you feel the pain, the type of pain (sharp, dull, burning, tingling, etc) and what makes it better or worse.
If you are experiencing pain, please rate the intensity from 1-5, with 1 being the lowest intensity and 5 being intolerable.
1
2
3
4
5
List any major illnesses, surgeries, or hospitalizations:
List any known allergies (foods, medications, environmental):
Are you currently pregnant or trying to conceive?
Yes
No
N/A
Try to conceive
Do you have a pacemaker or implant?
Yes
No
List all prescription medications, over-the-counter drugs, vitamins, herbs, or supplements.
Are you receiving any other treatments?
Chiropractic
Massage
Physical Therapy
Functional Medicine practitioner
Other
Tell us about your sleep. Do you get a full night's sleep? Is your sleep regularly interrupted? Please share details.
Please explain your diet (typical meals, dietary restrictions, sugar/salt/caffeine intake)
Please disclose any additional pertinent information to your health (physical, emotional, or mental health) that you feel may help us in your care:
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Should be Empty: