San Diego Chiropractic Group
5252 Balboa Ave Suite 901
San Diego CA 92117
858-560-5022
www.sdchirogroup.com

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(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.)

   

Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Authorization

***** Please make sure you have entered your full address above*****By signing below I:• Consent: to the collection and use of information to this office and release all information necessary to any insurance company or attorney for the purpose of claim reimbursement.• Assignment of Benefits: I grant use of my signature for insurance claims submission and assign benefits to this office for payments from insurance or attorney for services rendered at this office.• HIPPA: A copy of the Notice of Privacy is posted in the front reception. I will be presented with a copy of the notice for San Diego Chiropractic Group.• Massage and Acupuncture Cancellation Policy: No-calls, no-shows, and cancellations with less than 12 hour notice are billed at our normal cash rates. Arriving Late: As a courtesy to other clients and our therapists, arriving late may limit your treatment time. We will end your treatment at the scheduled time so that the next patient may not be delayed.

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

Signature


Finalizing Form


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