New Patient Form - Pregnancy - Lander Chiropractic

Patient Data

Name(Required)

First Last

Date(Required)

Email(Required)

Mailing Address

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Referred By

Age(Required)

Date of Birth(Required)

Social Security Number(Required)

Number of Children(Required)

Occupation(Required)

Employer

Marital Status(Required)

Spouse's Name(Required)

Spouse's Occupation(Required)

Spouse's Employer(Required)

Spouse's Health Status(Required)

Emergency Contact(Required)

Emergency Contact Phone(Required)

How would you like to receive appointment reminders?(Required)

email

text

Insurance Information

Name of party responsible for payment

Phone Number

Do you have health insurance?(Required)

Yes

No

Name of Company(Required)

Insurance Company Name(Required)

Contact Name(Required)

Phone Number(Required)

Claim #

Billing Address

Name of the Insured

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's Signature(Required)

Date

Spouse's or Guardian's Signature

Date

Medical History

Have you been treated for any condition in the last year?(Required)

yes

no

Please describe(Required)

Date of last physical exam(Required)

Have you had X-rays taken?(Required)

yes

no

Where were the X-rays taken?(Required)

Family History

Please list any family members and any past or current health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) If none, please enter none.(Required)

Call to Make an Appointment (714) 626-0074

New Patient Form – Pregnancy

Patient Data

Mailing Address

Questions Regarding Your Pregnancy

Insurance Information

Billing Address

Medical History

Have you ever:

Family History

Your Current Condition

Current Habits

Please check if you currently have or have a history of:

Lander Chiropractic