LAKEWOOD CHIROPRACTIC CLINIC

Scott Van Oosten, D.C.

PATIENT REGISTRATION FORM



Patient and Insurance Information
Telephone Number (Area code first): --
Full Name: (Last): (First): Email:
Street Address: City: State: Zip Code:
Sex: AGE: Birthdate: Single Married Widowed Divorced
Insurance Card Holder Employed by:
Phone number of Employer: -- EXT?: Occupation:
Who is Responsible for this account? : Relationship to Patient:
Patient Social Security # (optional) --
****Card Holder Social Security # (optional) --
****Card Holder Birthdate:
Name of Primary Insurance:
Identification Number:
In case of emergency please notify: Phone #:--

PLEASE BRING YOUR INSURANCE CARD FOR PROPER SUBMISSION TO YOUR INSURANCE CARRIER.



ASSIGNMENT AND RELEASE

I, the undersigned have insurance coverage with the above mentioned Insurance carrier(s) and assign directly to Lakewood Chiropractic Clinic., all medical benefits, if any - otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Lakewood Chiropractic Clinic., to release all information necessary to secure the payment of benefits. By checking this box I authorize the use of this electronic signature for my insurance submissions.

 

 

History and Physical Who referred you to our office?: Who is your Primary Care Physician?:
Reason for today's vist (CC):
Was there an injury?: Yes No. If so, date of Injury: Was it work related?: Yes No
Where does it hurt?: Does the pain radiate to anywhere else?:
Describe the pain (Check all that apply):Constant Comes & Goes Sharp Dull Achy Burning Numbness
How severe is your pain:
How long has it hurt?: Any other symptoms?:
What makes it better?: What makes it worse?:

Have you had any of the following treatments
Physical Therapy:Yes NoLength: Chiropractic:Yes NoType:
Cortisone Inj.:Yes No

 

 

Pain Clinic:Yes NoLength:
Medications: Yes No Names:
Other:Yes NoExplain:

Medical Problems: Please Select Self or family member indicate relation and type where applicable
Cancer: (Type and relation if applicable)

 

Heart Disease: (relation if applicable)
Diabetes: (relation if applicable)

 

High Blood Pressure: (relation if applicable)
List all current Medications:
List all past Surgeries:

Do you smoke?: Yes No Number of Children:
Type of work that you do:
Currently Working?: Yes No If no, date last worked:
Hobbies:

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