Patient Registration Form

Complete this form using your keyboard, then print it and bring it to your first appointment.

Please note: This form will not be submitted via the Internet, so security is not an issue. Print it, sign it and bring it with you to your first appointment.

Patient Information

Patient Name

Today's Date

Date of Birth

Social Security Number

Driver's License Number

Mailing Address

Phone

City

State

Zip

Cell

Beeper

E-Mail

Workplace

Employer

Work Phone

Address

Position

Job Description

Job Type (check one)

Full Time Part Time Temporary

How many hours per week do you work?

How long have you had this position? Years?

Months?

Spouse Information

Spouse's Name

Date of Birth

Social Security Number

Spouse's Employer

Work Phone

Business Address

Person responsible for this account

Method of Payment

Cash Check Credit Card

Insurance Information

Primary Medical Insurance

Who is the insured?

ID#

Group Number

2nd Insurance Company (if you have one)

Who is the insured?

ID#

Group Number

Your Vehicle Insurance

Date of Accident

Your Local Agent

Do you have an attorney?

Yes No

Name

Phone

Address

Social History

A. Marital status

B. If you are under 18, what is your parent's name?

C. With whom do you live? (circle one)

D. How many children do you have?

E. Were you born in the USA?

Yes No

If no, where were you born?

How long have you been a resident?

F. Please list your hobbies & how often you do them.

L. Education: How many years completed?

High School College Other

_________________________________________

Patient Signature or Legal Guardian

Medical History

Please list the reason for this visit & your symptoms.

List any doctor you have seen & any treatment you received for this problem.

List your family doctor & any other health problems.

List all medications you are taking.

Have You Ever Had? (Please explain.)

Surgery of any kind?

Broken bone(s)?

Accident(s) at work

Accident(s) auto

Accident(s) home

Accident(s) other

For Women Only

To the best of your knowledge are you pregnant?

Yes No

Menstrual cramps?

Yes No

Dry eyes?

Yes No

Birth control? If yes, what kind?

Yes No

Do You Suffer From?

Headaches Sinus problems Diarrhea Constipation Frequent urination Inability to hold urine Impotence Fatigue Other

Relative or friend to contact in case of emergency:

Phone

I understand that I am in a Chiropractic Office. Full payment for services rendered is due at the end of each visit. If for any reason this request cannot be met, arrangements must be made before seeing the doctor. I also understand that I am responsible for payment of services rendered and if I terminate treatment all fees are due and payable immediately.

ALL LEGAL AND COLLECTION FEES WILL BE ADDED TO THIS DEBT.

_____________________________________ ________________

Patient signature or parent/legal guardian Date

Acknowledgement, Understanding & Release

I hereby acknowledge that I am receiving (or about to receive) chiropractic healthcare services from Back & Neck Pain Center, and that I have been advised that the Doctor(s) providing the services is (are) willing to wait for payment for these services, provided that there continues to be a reasonable chance that payment will be made by insurance proceeds or out of the settlement of a liability claim.

I understand that if it is determined either (a) that there is no insurance company obligated to pay for the services, or if the insurance company involved refuses to acknowledge an assignment to Back & Neck Pain Center or make other provisions for the protection of the interest of the Center, or (b) if a liability claim exists, and my attorney refuses to agree to protect the interest of the Back & Neck Pain Center, or if I have not engaged the services of an attorney, then payment for services rendered by Back & Neck Pain Center will be made on a current basis and my account paid in full immediately. In any event, I hereby promise to pay my bill in full within ten (10) days from the date my liability claim is settled or after passage of three (3) months from the date of my last treatment, whichever comes first.

ALL LEGAL AND COLLECTION FEES WILL BE ADDED TO THIS DEBT.

I authorize the doctor and/or staff of Back & Neck Pain Center to release any information deemed appropriate concerning my physical condition and treatment to any insurance company, attorney, or adjuster in order to process any claim for the reimbursement of charges incurred by me as a result of professional services rendered and hereby release him/her of any consequence thereof. I agree that this office by given Power of Attorney to endorse/sign my name on any and all checks for payment of my balance due. I agree that photostatic copy of this agreement shall serve as the original.

________________________________________ _________________

Patient signature or Parent/Legal Guardian Date

Back and Neck Pain Center
John K. McKay, Jr., DC
Jan S. McKay, DC