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Name (First Name, Last Name)
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Preferred name/nickname
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Social Security #
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Birthdate (mm/dd/yyyy)
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Address (Street Address, City, State / Province, Postal / Zip Code)
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Phone Number
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Email Address
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May we send you text reminders?
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How did you hear about our office?
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Do you have health insurance?
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Type of Insurance
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Please enter your insurance policy number/member ID here (If you do not have insurance, just enter 0)
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Supplemental Insurance Information (If you have a supplemental insurance policy- please put the type (Aetna, BCBS, etc) here with the contract number. )
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Insurance Subscribers Date of Birth (If your insurance is through a spouse, parent, etc. Please provide their DOB in this box. )
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What is your height and weight? (necessary for posture analysis and thermal scans)
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What is your occupation? (Please include name of employer.)
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Gender
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Tell us about your health concerns:
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Please tell us about why you are here today
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Please list surgeries, traumas and any auto accidents here
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Does anything make your pain better or worse?
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Please provide a list of Medications here (if any)
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Continue to Fees
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Initial Appointment includes consultation and adjustment for $125
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Subsequent adjustments will be $65
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Add on Services Available for $50 a Session: Red Light Laser, Lumbar Decompression, Cervical Traction
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Signature
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Date Signed (mm-dd-yyyy)
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