Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.
Patient Name Today's Date
Date of Birth Social Security Number
Driver's License Number
Mailing Address Phone
City State Zip
Cell Beeper
WORKPLACE
Employer Work Phone
Address
Position Job Description
Job Type: Please check One Full Time Part Time Temporary
How many hours per week do you work?
How long have you had this position? Years? Months?
If lifting is required please check how often for each type.
1. Light never occasionally frequently constantly
2. Moderate never occasionally frequently constantly
3. Heavy never occasionally frequently constantly
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. Single Married Separated Divorced Widowed
B. If you are under 18, what is your parent's name?
C. With whom do you live? Please circle one Alone Parents Spouse
Children Other
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.
For the following, please check only one answer:
G. Do you smoke? Never Less than a pack a day 1-2 packs a day
2-3 packs a day 3-4 packs a day 5+ packs a day
H. Use of alcohol? Never Occasionally 1-2 glasses a day
2-3 glasses a day 3-4 glasses a day 5+ glasses a day
I. Use of coffee/tea? Never Occasionally 1-2 cups a day
2-3 cups a day 3-4 cups a day 5+ cups a day
J. Use of illegal drugs? Never Occasionally Frequently Constantly
K. Do you exercise? Never 1-2 days a week 3-4 days a week 5-6 days a week
Daily Excessively
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
Auto
Home
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? Yes No If yes, what kind?
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,
(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