In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. I also understand any services that have been properly billed and not payed within 90 days of service may be sent to a third party collections and subject to a 50% collectors fee for owed balance, any attorney's fees and a 2% interest per month. Lastly, I agree to call at least 2 hours prior to any missed appointments. failure to do so will result in a $25 fee

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Do you:

Have you ever suffered from:

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