New patient forms

Todays Date

SS/HIC/Patient ID #

Patients Social Security Number

Who may we thank for referring you?

Patient's Name*

First

Last

Middle

Patient's Address

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

Email Address

Sex

Male

Female

Birthdate*

Marital Status

Occupation

Employer / School

Employer / School Address

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

Employer / School phone number

Spouses name

First

Last

Spouses Employer

Home Phone Number

Cell Phone Number

Best time to reach you

AM/PM

Emergency Contact

Name

First

Last

Relationship

Home Phone

Work Phone

Insurance Information

Is this condition due to an accident?

Yes

Who is financially responsible for this account?*

Relationship to patient

Insurance Company

Group Number

Is the patient covered by additional insurance?

Yes

Subscribers Name

Subscribers relationship to patient

Subscribers Date of Birth

Subscribers Social Security Number

Agreement & Release

I certify that I, and/or my dependent(s), have insurance coverage with the company listed above and assign directly to Rocky Mount Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Rocky Mount Chiropractic may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Today's date*

Your relationship to the patient*

Digital signature of Patient, Parent, Guardian or Personal Representative *

Describe any falls that you've had along with the dates

Describe any head injuries you've had along with the dates

Describe any broken bones that you've had along with the dates

Describe any dislocations that you've had along with the dates

Describe any surgeries that you've had along with the dates

List any medications that you're currently taking

List any vitamins/herbs/minerals that you're currently taking

List any allergies that you have

Your pharmacy's name

Your pharmacy's phone number

TO BE COMPLETED IN OFFICE (SCROLL TO BOTTOM TO CONTINUE)

____________________________________________________________________________________________________

Signature of Patient, Parent, Guardian or Personal Representative

____________________________________________________________________________________________________

Printed name of Patient, Parent, Guardian or Personal Representative

____________________________________________________________________________________________________

Date of signing

Our website is a secure website however, by submitting this form with your information you understand that it could go through an insecure connection as it is sent to our office. We respect your privacy and confidentiality. If you would prefer your information not sent this way, please download a copy of the new patient form, print it, fill it out and bring it with you to your first appointment.

User agreement*

I understand

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New patient electronic form

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