Date: _____________ Home Phone: ________________ Work Phone: _______________ Cell: ______________
Name: _______________________________________________________ ( ) Male ( ) Female
First Middle Initial Last
Social Security Number: ___________________ Date of Birth: ____________________ Age: ______________
Address: _____________________________ City: ____________________ State: _______ Zip: ____________
Email Address: ________________________ ( )Single ( ) Married ( ) Widowed ( ) Seperated ( ) Divorced
Spouse's Name: ________________________________
Spouse's Dob: ________________________________
Spouse's Social Security Number: __________________
Spouse's Employer: ______________________________
Number of children: _______________
Patient Occupation: ______________________________ Employer Name: _____________________________
Who may we thank for referring you to our office/website: __________________Phone #:_________________
Who may we contact in case of an emergency?: ____________________Phone #:________________________
Chief complaints in order of severity: 1) ____________________________ for how long? _________________
2) ____________________________ for how long? _________________
3) ____________________________ for how long? _________________
Is this a work related injury? ______ Have you reported it to your employer? _______ Report made? _______
Is this injury due to an Automobile Accident?: ( ) yes ( ) no Was a report made?: ( ) yes ( ) no
Have you notified your Insurance company?: ( ) yes ( ) no
Auto Insurance Company Name: _______________________________________________________________
Auto Agent Name: __________________________________ Phone number: ___________________________
Your Personal Health Insurance Company: __________________________ Insurance ID#: _________________
Are you covered under ANY OTHER health policy through yourself or your spouse? ( ) yes ( ) no
If so, name of Insurance Policy Name Holder: _____________________ Name of Insurance: _______________
Method of Payment you plan to use to take care of today's charges?
( ) cash ( ) Check ( ) Visa ( ) Mastercard ( ) Payment plan
I understand and agree that (regardless of my insurance status), I am untimately responsible for the balance on my acount for any professional services rendered.
When applicable and without proper cancellation notice, Fiebiger Chiropractic reserves the right to bill you for missed appointments
Patient Signature: ______________________________________________ Date: _______________________
( ) Parent ( )Guardian Signature (if patient is a minor) ___________________________ Date: ___________
