Appointment Date: ___________________     Appointment Time: ___________________

What part of our body is injured?  ____________________________________________

Describe how your injury occurred: ___________________________________________
_________________________________________________________________________

 

Any X-Rays taken in the past 2 years? (Y or N) Is patient bringing X-Rays?(Y or N)

 

Name: _________________________________________________________________

                      (First)                                   (Middle Initial)                             (Last)       

Street: ___________________________ City: __________ State: ______ Zip: ________

Phone: (H) __________ (W) __________Date of Birth: _______ Age: ____  Sex: M / F

SS#: ________________________   Referred to this office by : ____________________

 

 

Your Employer: _______________________  Occupation: ________________________

Address: ___________________ City: ________________State: _______ Zip: ________

Spouse: __________Spouse’s Employer:________ Marital Status:S/M/D  #of Children__

 

 

Family Physician: ____________________________ Physician’s Phone #: ___________

Physician’s Address: _____________________ City: _________  State: ___ Zip: ______

Health Insurance: _____________________  ID# : _____________________________

(Please have card available)

 

Is the injury Work Related?  Y or N                      Is the injury Auto Related?  Y or N

If YES to either question, please answer the following:

 

Date of injury: ________________   Location of injury: ________________________

 

Insurance Carrier: ____________________ (Employers carrier if Work. Comp. injury)

 

Insurance mailing address: __________________ City: ________ State: ___ Zip: ______

 

Insurance Phone Number: (__)_________Fax#: (__)_____ Contact Person _________

 

WCB # ___________________________     Claim# ____________________________

 

The above information is true to the best of my knowledge.  I authorize my insurance benefits be paid directly to the doctor.  I understand that I am financially responsible for any balance.  I also authorize HealthSource Chiropractic or insurance company to release any information required to process my claims.

 

X  ___________________________________________________________________________________

                PATIENT/GUARDIAN SIGNATURE                                                         DATE
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