Handley Chiropractic Clinic Patient Entrance Form
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5HANDLEY CHIROPRACTIC CLINIC
Dr. Leonard Handley, D.C.
PATIENT ENTRANCE FORM
727 Gardiners Road | Kingston, ON K7M 3Y5
(613) 384-1008 ●
PATIENT INFORMATION
:
Patient Name: .............................................................................................................................................................................. Date: ............................................
Address: ...........................................................................................................................................................................................................................................
City/Province: .............................................................................................................................................................................. Postal Code: .................................
Tel#
(
) .......................................................Tel#
(
) ............................................................. Email: ..................................................................
(home):
(work):
Date of Birth
: ...................................................
Age: .................... Marital Status
:
Single
Married
Divorced
Widowed
(dd/MMM/yy)
(please check)
Spouse’s Name: .................................................................... No. of children: ................Names: ........................................................................................................
Closest Relative: .................................................................... Relation: ........................................................................................ Tel#: (
) ..................................
Your Occupation: ..............................................................................................................................................................................................................................
Employer: .........................................................................................................................................................................................................................................
Address: ...........................................................................................................................................................................................................................................
City/Province: .............................................................................................................................................................................. Tel#: (
) ..................................
Extended Health Care Company (insurance) : ................................................................................................................................ Policy #: .......................................
Insurance Credit Card No.: ............................................................................................................................................................ Exp: .............................................
How did you hear about our clinic?
:
website
phonebook
friend
sign
other ....................................
(please check)
CLAIM WILL BE MADE AGAINST:
1) Recent motor vehicle accident
YES
NO
(If YES, see attached)
2) Work related injury/accident
YES
NO
(If YES, see attached)
PRIOR CHIROPRACTIC CARE:
Name: ........................................................................................................................................................................ Tel#: (
) ..................................
Were X-Rays taken?
YES
NO
: .......................................... Results
:
excellent
good
fair
poor
If YES, date taken
(pls check)
MEDICAL DOCTOR:
Doctor’s Name: .......................................................................................................................................................... Tel#: (
) ..................................
Clinic: ......................................................................................................................................................................... City ...............................................
Date of Last Appointment: ................................................................................. Date of Last Physical .............................................................................
REASON FOR CONSULTING OUR CLINIC:
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................
Expectations: ...................................................................................................................................................................................................................
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C:/My Documents/CLINIC FILES/CLINIC Forms/HANDLEY Patient Entrance.doc [last updated on 11-NOV-2010]
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