Registration & History

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Patient Information


In case of emergency, contact:



I, the undersigned, certify that I (or my dependent) have insurance coverage with

and assign directly to Chiropractic Office 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 hereby authorize the doctor(s) to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Patient Condition

Add how severe is your pain today 0=No Pain, 10=Intolerable

Health History

Date of Last:

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