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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

(AUTO ACCIDENT ONLY) please provide:

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

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 authorize direct payment from my attorney or insurance company to pay the provider directly.

Signatures

Patient's signature _______________________________________________

Spouse's or guardian's signature __________________________________

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Office Hours

DayMorningLunch
Monday9:00am - 6pm1pm -3:00pm
Tuesday9:00am - 6pm1pm -3:00pm
Wednesday9:00am - 6pm1pm -3:00pm
Thursday9:00am - 6pm1pm -3:00pm
Friday9:00am - 1pmClosed
SaturdayBy AppointmentBy Appointment
SundayClosedClosed
Day Morning Lunch
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am - 6pm 9:00am - 6pm 9:00am - 6pm 9:00am - 6pm 9:00am - 1pm By Appointment Closed
1pm -3:00pm 1pm -3:00pm 1pm -3:00pm 1pm -3:00pm Closed By Appointment Closed

Testimonial

"Observational study found that low back pain patients receiving chiropractic care, which typically includes spinal manipulation, are more satisfied than those receiving medical care."
-New England Journal of Medicine

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