New Patient Application
Corradino Chiropractic PIN#________________
PATIENT INFORMATION & CONDITION FORM
Patient Name: __________________________________________________________________________Today's Date: ____/____/____
Social Security Number ________________________ Birth Date: ____/____/____ Age: _____ Gender: F M
If you are under 18 years of age, who are your legal parents or guardian?
Father: ____________________________________________Date of Birth: ____/____/____ Phone: (______) ________________
Mother: ___________________________________________Date of Birth: ____/____/____ Phone: (______) ________________
Guardian: ___________________________________________Date of Birth: ____/____/____ Phone: (______) ________________
Who do you normally live with? Mother and Father Father Mother Legal Guardian None
Marital Status: Married Separated Widowed Single How many children? ____________
CURRENT ADDRESS
Street__________________________________________________________________________________________________________________
City _______________________________________________________________State ________ Zip___________________________
Phone (_______) ___________________
OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside)
Street_________________________________________________________________________________________________________________
City ______________________________________________________________State ________ Zip ___________________________
Phone (_______) ___________________
Your Occupation ____________________________________________Employer___________________________________________
Work Address _______________________________________________________________________________
Work Phone (______) ________________
Student at ______________________________________________________________________________________
FULL-TIME PART-TIME
Name of Spouse _____________________________________________________________Spouse's Date of Birth ____/____/____
Spouse's Occupation ____________________________________________Spouse's Employer _____________________________
Spouse's Work Address _____________________________________________________________________
Work Phone (______) ________________
Spouse is a student at __________________________________________________________________________
FULL-TIME PART-TIME
Who should we contact in the event of an emergency? ___________________________________________
Phone (______) ________________
Address of contact person _______________________________________________________________________________________
How did you learn about us? ______________________________________________________________________
Is your condition or injury due to an accident or work-related cause? YES NO Please check ALL that apply.
Did the condition or injury result from automobile accident? YES NO
Did it result from a work-related accident or cause? YES NO (briefly describe): ___________________________
If the condition did not result from an automobile accident or relate to your work, where did the accident occur? ______________________________________________________________________________________________________________________________
Approximately, when did your injury or condition occur? ____/____/_____
Describe your condition, symptoms, or the purpose of this appointment: ______________________________________________
__________________________________________________________________________________________________________________________________
Have you ever had the same or similar condition? YES NO If yes, when and describe: _________________________________________________________________________________________________________________________________________________________________
Please indicate any other healthcare providers who you've seen for this injury or condition, and when you last saw them.
Name: ___________________________________ Type of Practice: ______________________________
Date of Last Visit: ____/____/_____
Name: ___________________________________ Type of Practice: ______________________________
Date of Last Visit: ____/____/_____
Name: ___________________________________ Type of Practice: ______________________________
Date of Last Visit: ____/____/_____
Date of last physical examination? ______________________________________________
What surgery have you had? ____________________________________________________________
When? _______________________________
Serious illnesses or conditions? __________________________________________________________
When? _______________________________
Have you been treated for any health condition by a physician in the last year? YES NO Describe: _______________________________________________________________________________________________________________
What medications or drugs are you taking?________________________________________________________________________
Have you ever suffered from:
Dizziness Arthritis Digestive Disorders
Backaches Headaches Nervousness
Heart Trouble Numbness Sinus Trouble
Diabetes Asthma Anemia
Hernia Neuritis Cancer
WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? YES NO
Do you have health insurance? YES NO Not Sure
Company: ___________________________________________________
Full Name of Policy Holder: ___________________________________ Policy Holder's Date of Birth ____/____/_____ Does the policy holder have the insurance through his/her employer? YES NO
If yes, who is the employer? _____________________________________
******************************************************************************
I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself -- not between my insurance company and this office. I agree to pay my estimated patient responsibility and further understand that the estimated responsibility is neither a guarantee of payment by my insurance company, nor necessarily an accurate reflection of my actual responsibility as determined by my insurance company upon processing of my claims. In the event that my insurance company does not pay on my charges at the estimated rate or within a reasonable period of time, upon request of this office I will immediately pay the balance owing on my account unless otherwise agreed to in writing. I understand that an interest charge may appear on all accounts over 90 days. I further understand and agree, that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse this office for all costs of such collection efforts, including, but not limited to, all court costs and attorney fees.
I authorize this office to release any medical information relating to my treatment to any insurance companies which may be responsible for paying benefits to me, and to any attorney s who may be representing me due to my condition, and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance companies, attorneys, or other payers.
I have read, understood, and agree to the foregoing. The information which I have provided is true and complete to the best of my knowledge.
Patient's Signature: __________________________________________________________________ Date: ____/____/_____
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