Patient Information

Date

Patient SSN

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone/Mobile

Date of Birth

Age

Sex

Male

Female

Occupation

School Name

Employer's Name

School Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Employer's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Employer's Phone

School's Phone

First Name

Middle Name

Last Name

Spouse's Date of Birth

Lawyer / Attorney's Name

Lawyer / Attorney's Phone Number

Primary Care's Name

Primary Care's Phone Number

Referred Patient/Friend's Name

Insurance

{inputs.Patient} we need your Insurance information

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes

First Name

Middle Name

Last Name

Birthdate

SSN

ASSIGNMENT AND RELEASE
by checking this box I certify that I and/or my dependent(s), have insurance coverage with and assign directly to ARTISAN CHIROPRACTIC CLINIC, LLC all insurance benefits. If any, otherwise payable to me for services rendered. I understand that am financially responsible tor all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature

Sign Here