Patient Information Form

ACCOUNT INFORMATION

Person ultimately responsible for the account:

Last:________________________________________ First: :______________________________________ M.I_______

Relationship:________________________________________________________________

Billing Address:

Street_______________________________________ City/State_____________________________ Zip______________

SS#______/____/_______ Drivers License#:______________________________________

Date of Birth: ____/______/______ Work Telephone #:_____________________

Patient Information Form
Name: . First: _________________________________________ M.I_______ Last:_________________________________________ Called Name________________________________________ Date:_________/_______/______ Street_________________________________________ City____________________State_________ Zip______________ Phone#:__________________________Work#_________________ Cell#:________________________________________ Email Address:_________________________________________________________________________ Sex:_____Marital Status:____________ DOB:_____/_________/_____ SS#______/______/_______
Referred by:___________________________________Occupation:_____________________________________
Patient's: Occupation:______________________________________Employer:___________________________________________ Business Address: Street______________________________________City/State______________________________ Zip______________ Business Phone:______________________
Name of Spouse or Parent if a Minor: Last:_________________________________________First:______________________________________ M.I_______ Occupation:_________________________________________ Employer:______________________________________ Street________________________________________City/State______________________________ Zip______________
PERSON RESPONSIBLE FOR PAYMENT: _________Self _________ Spouse _________Parent_________ Other ___________ If Other: Last:_________________________________________ First: :___________________________________ M.I______ Street________________________________________ City/State________________________________ Zip____________ SS#______/______/_______ Phone#:___________________ Cell#:_______________________
FEES ARE PAYABLE WHEN SERVICE RECEIVED (Unless Special Arrangements Have Been Made)
Medical Information: Have you had Chiropractic care before? _____Yes _____No If yes, Doctor's Name:____________________________________________________________________________________ Please describe the pain & location:_______________________________________________________________________ When did the condition begin? ___/____/____ Similar condition in past? _____Yes _____No
Please list anything to which you may be allergic:____________________________________________________________ List any PAST serious accidents with dates:__________________________________________________________________
Are you wearing: Heel Lifts ______Sole Lifts_______Inner Soles______ Arch Supports______
FOR WOMEN:
Are you taking Birth Control? ____Yes ____No	Pregnant? ____Yes _____ No Nursing? ____Yes _____No
IN EVENT OF EMERGENCY Who should we contact?__________________________________________________________________________________ Relationship to patient:________________________Contact Telephone#:_______________________________________
ACCOUNT INFORMATION Person ultimately responsible for the account: Last:________________________________________ First: :______________________________________ M.I_______ Relationship:________________________________________________________________ Billing Address: Street_______________________________________ City/State_____________________________ Zip______________ SS#______/____/_______ Drivers License#:______________________________________ Date of Birth: ____/______/______ Work Telephone #:_____________________
PAYMENT METHOD: Cash:_____ Check_____Insurance_____ Carrier:______________________________ Policy/Group ID#: ___________________________Check if Co-pay________ Credit Card: Visa_____MC_____AmEx_____CC Number:_____________________________Exp.Date:_____/____/_____ Name on Card:___________________________________________________________________________________________
* We Invite you to discuss with us any questions regarding our services. The best health service is based on a friendly mutual understanding between provider and patient. * Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If the account is not paid within 90 days of the date of Service and no financial arrangements have been made, you will be responsible for legal fees, Collection Agency fees, and any other expenses incurred in collecting your account balance. By furnishing your credit card number information, you authorize the South Texas Chiropractic group to automatically charge any outstanding balances after 60 days. You also authorize us to submit directed payment claims to your insurance carrier. * I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status.
Signature:___________________________________________________________________ Date:_____/______/______