new patient forms – Lifeline Chiropractic

1About You

2Insurance Info

3Reason For Visit

4In Event of Emergency

5Health history

6Account info

Co. Name(Required)

First

Address(Required)

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

Phone #(Required)

Insured's SS#(Required)

Group(Required)

( Plan, Local or Policy# )

Insured's Name(Required)

Relation(Required)

Date of Birth(Required)

Insured's Employer(Required)

Please Inform front desk of 2nd. Insurance source.

Person ultimately responsible for account

Name

Relation

Address

Street Address City State / Province / Region ZIP / Postal Code

SSN

D.L.#

Work Phone#

Payment method

Cash

Check

| hereby authorize assignment of | my insurance rights and benefits directly to the provider for services ren- dered. | fully understand | am solely respon- | sible for any balance not paid by my insur- /ance company (if offered at this office).

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider and or managed care organization, to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

Singnature

Adult Patient

Parent or Guardian

spouse

Date

Name

First Last

About You

Subscribe to get exclusive updates

Quick Links

Our Services

Contact Info

Copyright© Lifeline Chiropractic. All Rights Reserved.