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Patient Intake Form

Patient Information

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Personal Information

Contact Information

*First Name: Middle Name: *Last Name: *Gender: Female Male *Date of Birth: Social Security #: Height: 0 1 2 3 4 5 6 7 8 9 Feet 0 1 2 3 4 5 6 7 8 9 10 11 Inches Weight: Marital Status: Single Married Divorced Widowed Other Spouse's Name: Number of Children: None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20     Emergency Contact: Relationship: Phone:

*Email:   (We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.) *Home Phone: Cell Phone: Work Phone:     Country: Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and The South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Address Line 1: Address Line 2: City: State/Province/Region: AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY AB BC MB NB NL NT NS NU ON PE QC SK YT *Zip/Postal Code:

Draw Your Symptoms

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Click on a crayon and draw on the body above to indicate your symptoms

How did you find out about our office?

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Referring Physician:
Referring Patient:
Referred by:	Ad Another Provider Attorney Employee Existing Patient Friend Internet Local Merchant Phone Book Physician Provider Manual

Did you hear about our office from an advertisement?

No Yes

If Yes, Where:

Did you hear about our office from a phone or professional directory?

No Yes

If Yes, Where:

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Employment Information

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Regular Work Status:	Employed Full-Time Student Part-Time Student Part-Time Employed Retired Unemployed
Employer Name:
Employer Address:
Employer City:
Employer State:	-U.S.- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY -Canada- AB BC MB NB NL NT NS NU ON PE QC SK YT
Employer Zip:
Occupation:
Supervisor Name:
Supervisor Phone/Extension:
Physical Work Duties:

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What is the purpose of your visit?

Wellness Complaint Injury Other

Insurance & Payment for Care

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How do you plan to pay for care?

Personal Insurance Third-Party Insurance No Insurance, Self-Pay

Name of Party Responsible for Payment:
Responsible Party Phone:

Primary Insurance	Secondary Insurance
Insurance Name: Phone: Address: City: State: -U.S.- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY -Canada- AB BC MB NB NL NT NS NU ON PE QC SK YT Zip: ID/Policy #: Group #: Insured's Name: Insured's Date of Birth:	Insurance Name: Phone: Address: City: State: -U.S.- AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY -Canada- AB BC MB NB NL NT NS NU ON PE QC SK YT Zip: ID/Policy #: Group #: Insured's Name: Insured's Date of Birth:

If an auto accident, please provide:

Claim #:
Insurance Contact Person:
Insurance Phone:
Attorney's Full Name:
Attorney's Phone:

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Authorization

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 or treatment.

* I agree with this statement of authorization

Name of the Insured: (Please Print)	_____________________________________________
Patient's/Guardian's signature:	_____________________________________________	Date:	__________

Signature

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