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Note Fill out as much information as possible. We cannot process your order without the essential parts of this form being filled out. If an order is sent in with too little information, we shall simply delete it. Also note that you only have to fill out this form once. After that you only have to login to set up an appointment.
Section One
1. First Name
2. Last Name
3. Who can we thank for referring you to this office ?
4. Nick Name
5. Is this for
6. Primary reason for consulting our office
7. Any other associated warning signs or complaints ?
8. How long has this been going on ?
9. Any previous incidents in your life ?
Section Two
10. Your form of payment
11. The doctor you wish to see
12. Your Address
13. City
14. State
15. Zip
16. Gender
17. Social Security Number
18. Birth Date
19. Marital Status
20. Home Phone
21. Cell Phone
22. Fax
23. Email Address
24. Do you have children ?
25. If yes how many ?
26. Relation
Section Three
27. Employers Name
28. Office Phone Number
29. Occupation
30. Work Address
31. State
32. City
33. Zip

Section Four
34. Are you a student?
35. School
36. Who is financially responsible?
37. If other are they a patient here?
38. Relationship
Section Five
39. Is your condition due to an accident ?
40. Date of Accident
41. Type of accident
42. Have you ever been in an auto accident ?

Section Six
43. Have you ever seen another chiropractor ?
44. If yes, who
45. Number of visits
46. Have you had any xrays in the last two years ?
47. Area Xrayed
48. Location where xrays were taken
49. Name of MD
50. Others seen for this condition
51. Are you a Medicare patient?
52. If you had an accident was it your fault?
53. Do you have Medical Payments?