New Patient Welcome Form | Schuver Chiropractic

Today's Date

Patient's First name

Patient's Last name

Patient's Date of Birth (MM/DD/YYYY)

Patient's FULL address (Road, City, State, Zip)

Patient's Phone Number(s)

Who is the patient's employer? How long have you worked there? What is their address and telephone number? What do you do? If you are retired tell us what you did do?

Who referred you to our office? How did you hear about us?

What is your chief complaint?

Have you been treated medically for this condition?

Yes

No

If yes, by who? And, what was their treatment plan?

If so, when did it occur? Provide us details...

When did your condition begin?

Is it worse than it was?

Yes

No

Constant

Comes and Goes

What activities aggravate your condition? (Select all that apply)

Work

Sleep

Exercise

Daily routine

Your Insurance Company

Your Policy #

Insurance Company FULL address (should be located on your card)

Marital Status

Married

Divorced

Widowed

Single

If married, what is your spouse's name?

Their Date of Birth (MM/DD/YYYY)

Their contact information

If you have children, list their names and ages

Who is your emergency contact and what is their contact information?

Please tell us about your past illnesses, severity, and type of injury. Include dates. Car Accident, Fractures, Tumors, Surgeries, etc.

Have you had any recent X-rays, CT scans or MRI? If so, where and when?

Are you pregnant? If so, when are you due? Any known complications?

Any recent doctor visit we should know about?

Do you agree to our our policy requiring payment in full for all services received at the time of visit unless other arrangements have been made. Please let us know if you have insurance which may cover your visit.

Yes, I Agree

I authorize the staff to perform any necessary services needed during diagnosis and treatment and the release any information required to process insurance claims. I authorize the release of any medical information which may be pertinent to my case.

Yes, I agree

I understand that I may be financially responsible for any charges incurred at this office including co-pays, deductibles, and charges denied or not covered by my insurance company.

Yes, I Agree

Please sign this form by typing your name. (Parent or Guardians must type their name if the patient is under 18)