Welcome to the Office
Confidential Patient Information 


Name:______________________________________________ Hm Phone: (     )______________

Home Address:_______________________________________ City:_______________________ 

E-Mail: ____________________________________________  Zip Code:___________________

Spouse‘s Name:______________________________________ Wk Phone:__________________

Nearest Relative not living with you:_____________________  Phone:_____________________

Family Physician:____________________________________  Phone:_____________________

Landlord:__________________________________________ Phone:______________________

Whom may we contact in the case of an emergency:___________________________________

Phone:____________________________

Whom may we thank for referring you to us?_________________________

Phone:____________________________

Social Security #:____________________ Date of Birth:_______________Age_____

Marital Stat. M  S  D  W            Children________

Occupation_______________________________________________________

Employer_________________________________________________________

Address__________________________________________________________

City_______________________________State____________Zip___________

Work Phone (          )  ____________________________EXT.______________

Describe Symptoms Briefly



Is this an auto accident:          N      Y      Date__________________________

Is this an on the job injury?   N       Y      Date__________________________

Ever had same/similar conditions?   N    Y     __________________________

Other doctors seen for this conditon?             __________________________

Other Health Problems?   __________________________________________

Are you on any medications? (aspirin ect.?)________________________________

Do you smoke?   N       Y  -   Quantity  ________________________________

Do you exercise regularly?     N       Y  

Who is responsible for this bill?________________________

I will be paying today by cash: check: credit card:

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or the above information. I clearly understand that I will be liable for Attorney’s fees and Interest at 1.5 % (one and one half) per month if my account goes to collection. 




Patient Signature__________________________________________________ Date_____________