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Please Complete and Print these forms, ready for your visit. (Time Saver)
Please list any operations: Other Serious illnesses: Have you ever had Chiropractic care? Dr: Significant family history (who):
Heart Disease: Diabetes:Cancer: Type: Stroke: Other: Allergies
Food:
Drugs:List any medications you are presently taking:
FEES ARE PAYABLE AT TIME OF X-RAYS, EXAMINATIONS AND TREATMENTS UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE.
I understand and agree that health/accident insurance policies are an agreement between an insurance carrier and myself I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I hereby authorize the above named Doctor or Clinic to furnish information concerning my present illness or injury and DIRECT the insurer to pay, without equivocation directly to the above named DOCTOR or CLINIC, any and all benefits due them as a result of this claim. I am also aware that I am personally responsible for charges and/or balances not covered by my insurance. I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties as the original copy. I also agree to pay any costs of collection should this account become delinquent and reasonable attorneys fee, and hereby waive my rights to exemption under the laws of the state of Alabama and any other state. I also understand that any unpaid balance over 30 days will be subject to a $5.00 a month billing fee and/or 1 1/2% monthly service fee.
I consent to any physical examination, x-ray study, laboratory procedures, Chiropractic or adjunctive therapy or clinic service that is ordered under general and specific instruction of the doctor.
Patient's Signature Date Guardian or Insured's Signature Date
Authorizing Care_______________________________ _____________ _______________________________ _____________ Click here to complete Page 2. (Required) | Back to Patient Forms Page.