Website New Patient Registration Form, Insurance, Consent, Scheduler

New Patient Registration

Please fill in the form below
Name *

First Name Middle Name Last Name
E-mail *
Sex
Date of Birth

Month Day Year
Contact Number: *

- Area Code Phone Number
Marital Status

Mailing Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Taking any medications, currently?

Yes No
If yes, please list it here
List the area(s) that are bothering you today?
Scale of 1-10 what is your pain level today. 10 being the worst pain of your life?
Insurance Information
Name of Medical Insurance
Insurance ID Number
Insurance Group Number
Insurance Customer Service/Provider Phone Number From Back of Card
Primary Insurance Holder Name
Primary Insurance Holder Date of Birth
Secondary Insurance
Please list Insurance Name, ID, Group, and Phone Number
Informed Consent

I will use my hands or a mechanical instrument upon your body in such a way as to move your joints. This procedure is referred to as ”Spinal Manipulation” or Spinal Adjustment” As the joints in your spine are moved, you may experience a “pop” as part of the process.I will use my hands or a mechanical instrument upon your body in such a way as to treat the affected muscles groups. There are certain complications that can occur as a result of a spinal manipulation. These compilations include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, fractures, strains and dislocations, Bernard-Horner’sSyndrome (also known as oculosympathethetic palsy), costovertebral strains and separation. Rare complications include, but are not limited to stroke. The mos common complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment. I am aware of these complications, and in order to minimize their occurrence I will take precautions. These precautions include, but are not limited to my taking a detailed clinical history of you and examining you for any defect which would cause a complication. This examination may include the use of x-rays. The use of x-ray equipment may pose a risk if you are pregnant. If you are pregnant,you should tell me when I take you clinical history.
I have read the above and agree to receive treatment From Dr. Dominique Taylor *

Yes No
Please Type Your Full Name as Signature *
Date *

- Month - Day Year
Date
Schedule an Appointment / Or Confirm Current Scheduled Appointment

If scheduling for the first time you will receive a confirmation call from our office for this appointment.
Date

- Month - Day Year
Date
Time

: Hour Minutes
Should be Empty:

New Patient Registration

Insurance Information

Secondary Insurance

Informed Consent

Schedule an Appointment / Or Confirm Current Scheduled Appointment