Name:
Billing Address:

New Patient Form 4 of 4
Alexandria Chiropractic Center

Pain Chart
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Relation:
Work Phone:

Social Security Number: - -
Drivers License Number: State:
Height: ft. in. Weight lbs.
Person ultimately responsible for this account:

Please mark area(s) of injury or discomfort as shown below in the example. Indicate the degree of pain using a scale of
1 (discomfort) to 10 (extreme pain). Print this form and mark on diagram with a pencil in case of mistake.

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If your account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.
I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status.

 

Signature: _________________________________________________ Date: ____/____/______