southcenterchiropractic.comc - New Patient Registration

New Patient Registration
Please note that all information is strictly confidential.

Please help us to provide you with a thorough evaluation by taking the time to fill out this form carefully. Here at this office we offer chiropractic, massage and rehab. The health information you provide can be used for any of those services. If we believe that we cannot assist you with your health care needs, we will be more than happy to refer you to the appropriate health care professional. If you have any questions, please let us know.
Thank you
Name

First NameMiddle NameLast Name
Nickname
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Social Security #
Marital Status

SingleMarriedDivorcedWidowedLife Partner
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Primary Contact Number

HomeWorkCell
Contact Number
Please enter a valid phone number.
Cell Phone Carrier
Please enter a valid phone number.
E-mail address
example@example.com
Occupation
Employer
Primary Care Physician
Phone Number
Please enter a valid phone number.
Spouse
Children & Ages
In Case of Emergency, Contact
Relationship
Phone Number
Please enter a valid phone number.
How did you hear about our office/whom may we thank for referring you?
Seeking treatment due to an injury?

YesNo
If yes

AutoWorkOther
Date of Injury

MonthDayYear
Date
Insurance Information
Primary Insurance

NoneHealth/MedicalAutomobileL&I/Workers’ Compensation
Name of Insurance Company
Prefix
ID#
Group #
Name of Insured
Relationship to Patient
Secondary Insurance

NoneHealth/MedicalAutomobileL&I/Workers’ Compensation
Name of Insurance Company
Prefix
ID#
Group #
Name of Insured
Relationship to Patient
I understand that any quotation of benefits is NOT a guarantee of payment, and the agreement is between the Insurance Carrier and me. I authorize any and all payments from my insurance carrier directly to this office with the understanding that all monies be credited to my account upon receipt. Any denial of payment becomes my responsibility (patient).
I certify that the above information is correct and true.
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Registration

Insurance Information