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In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

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 _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

Exclusive offer
First visit 30$ which includes intake, exam and adjustment

Office Hours

DayOpenClosed
Monday9:00am6:00pm
Tuesday9:00am6:00pm
WednesdayClosedClosed
Thursday9:00am6:00pm
Friday9:00am6:00pm
SaturdayBy Appt.Closed
SundayClosedClosed
Day Open Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am 9:00am Closed 9:00am 9:00am By Appt. Closed
6:00pm 6:00pm Closed 6:00pm 6:00pm Closed Closed