PATIENT NAME:___________________________________
FILE NO:___________________

WELCOME
The doctor and staff of Balanced Body Chiropractic Wellness welcome you and want to provide you with the best possible care. We will conduct a thorough history and physical examination to decide if we can assist you. If we do not believe that your condition will respond to chiropractic care, we will not accept you as a patient but will refer you to another health care provider, if appropriate.

INSURANCE
This office will process your insurance forms upon request. We will do our utmost to provide sufficient information to your carrier to obtain payment for your treatment. We have found that, in some instances, however, insurance companies will deny or reduce payment despite our best efforts to demonstrate the necessity for care. In the event that full payment is not made for any reason, you must understand that you are responsible to make payment in full.

PATIENT IDENTIFICATION
_________________________________________
Name
_________________________________________
Street
_________________________________________
City, State and Zip
_________________________________________
Social Security #
Male ( ) Female ( ) Name or Nickname I prefer to be calledin this office _______________________________

Telephone (Home) __________________________
(Work) _________________________
Ok to call there? Yes ( ) No ( )
_________________________________________
Occupation
___________________________ _____________
Date of Birth                           Age
Contact in case of emergency, Name: _______________________________________________________
Telephone # ______________________________________
Name of Parent of Minor Patient (If applicable) _______________________________________________

ACCEPTANCE AS PATIENT
I understand and agree that the doctor of Balanced Body Chiropractic Wellness has the right to refuse to accept me as a patient at any time before treatment begins. The taking of a history and the conducting of a physical examination are not considered treatment, but are part of the process if information gathering so that the doctor can determine whether to accept me as a patient.

____________________ ______________________________
Date                          Signature