Patient Information printable pdf download

WELCOME

The doctor and staff of Pearson Chiropractic Office 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. PLEASE PRINT CLEARLY!

Patient Information

Name: (First, Middle, Last) ____________________________________________________________ Date of Birth: ______________________________

Name you would like to be called:____________________________ Sex: M F Marital Status: Single Married Widowed Divorced

Address: ________________________________________________________ City, State, Zip: _________________________________________________

SOCIAL SECURITY NUMBER: (MUST BE FILLED OUT). _________________________________ Race:____________________________________________

Home Phone: _______________________________ Cell Phone: ______________________________ Work Phone: _____________________________

Email Address:______________________________________________________

Would you like to receive appointment reminders? Please select one or both.

Email By Text Message, please provide cell phone carrier______________

In an effort to reduce paper waste, we would like to offer another option for receiving statements. Please select only one.

I would like to receive my statements by: Email Mail

Employment Information

Employment status: Employed Unemployed Retired Part‐time Student Full‐time Student Other

Employer: __________________________________________________________ Occupation: _________________________________________________

Responsible Party Information‐ If you are over the age of 18, please indicate self as responsible.

Relationship to patient: _______________________________ Name (if other than self):_______________________________________________________

Address: ______________________________________________________ City, State, Zip: ___________________________________________________

Responsible Party’s Phone#: _______________________________________________________

Emergency Contact

Name: _____________________________________________________________ Relationship to Patient: _______________________________________

Phone #: _______________________________________________________________________________________________________________________

Is Your Illness or Injury Related to Any of the Following?

Employment Emergency Accident Auto Accident (State of Auto Accident) ___________________________________________

If Employment related, has employer been notified? YES NO

How Were You referred to Our Office?

By an Attorney By a Doctor By a Patient Yellow Pages Location Website Other

Please print the name of your source: ________________________________________________________________________________________________

ACCEPTANCE AS PATIENT

I understand and agree that the doctors of Pearson chiropractic have 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 on information gathering so that the doctor can determine whether to accept me as a patient.

Date: ______________________________ Signature: ______________________________________________________________________

Patient Information