• Joyful Roots Chiropractic

    935 Russell Ave, Unit A, Gaithersburg MD 20879 Phone (301) 540-3111

  • Patient Information:

  • Sex:*
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Chiropractic Experience:

  • Where did you hear about us?*
  • Have you been adjusted before?*
  • Have any family members ever seen a wellness chiropractor?*

  • Reason for this Visit:

  • What may have contributed to your chiropractic need?*
  • Has this concern:*
  • Does this concern interfere with:*

  • Insurance Information:

  • I certify that I’m the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I’m responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care of treatment.

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: