New Patient Intake

Contact Information

First Name:

Last Name:

Date of Birth:

Home Phone:

Mobile Phone:

Work Phone:

E-mail:

Street Address:

City:

State:

Zip Code:

Emergency Contact Name:

Phone:

Relationship

Primary Care Provider Name:

Phone Number:

City:

State:

Employer/Company Name:

Phone Number:

City:

State:

Job Title/Position:

Financial Information

Primary Insurance Coverage:

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Policy holder’s Name:

Policy Holder's DOB:

Secondary Insurance Coverage:

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Policy holder’s Name:

Policy Holder's DOB:

Financially Responsible Party

Self Other

(If other please complete section below)

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Referring Provider (if applicable)

I was not referred. I was referred by my primary care provider (same doctor listed on the first page). I was referred by another doctor (please fill out doctor information below).

Referring Provider Name:

Phone:

E-Mail:

Street Address:

City:

State:

Zip Code:

ASSIGNMENT OF BENEFITS AND RELEASE OF RECORDS

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Dailey Chiropractic, Inc. (Laura R. Dailey Wise, D.C.) 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.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purposes 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.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Signature of Patient, Parent, Guardian, or Personal Representative

Date

Relationship to Patient

Medical Information

Reason For Your Visit

Wellness & Health Maintenance

Injury, Pain Complaint, or Ailment

Date of Injury/Onset:

Accident Auto accident/other accident

Date of Accident:

State Where Accident Occurred:

What do you feel caused your condition?

Is the condition getting progressively worse?

Yes No

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How often do you have this pain?

Constant frequent Intermittent Occasional

Other:

Does the pain interfere with your:

Work

Sleep

Daily Routine

Recreation

Activities or movements that are painful to perform:

Sitting

Standing

Walking

Bending

Lying down

What treatments have you already received for your condition?

Medications

Surgery

Physical Therapy

Chiropractic Care

None

Other

Other:

Name and address of other doctor(s) who have treated you for your condition:

I understand that the information I have provided above is current and complete to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Signature:

Date

Privacy Notice

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Privacy Notice

I have received Dailey Chiropractic, Inc.’s Notice of Privacy Practices, which describes this agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Client (or Personal Representative)

Date

Your information will be encrypted.