LAKZ10 Patient Registration

Patient Registration

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Age *

Phone Number *

Please enter a valid phone number.

Email

example@example.com

Street Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Insurance Information

Employer Phone Number

Please enter a valid phone number.

Occupation

Who is responsible for this account?

Relationship to Patient:

Name of Primary Insurance

Insurance Identification Number:

Insurance Type

Group Number

Individual Number

Cardholder Date of Birth

Date

In case of emergency please notify:

First Name

Last Name

Please attach a photo of the FRONT side of your insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Please attach a photo of the BACK side of your insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

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 visit (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

Come & Goes

Sharp

Dull

Achy

Burning

Numbness

Other

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

No

Length

Cortisone Inj.:

Yes

No

Medications:

Yes

No

Chiropractic:

Yes

No

Type

Pain Clinic:

Yes

No

Length

Other:

Yes

No

Explain:

Medical Problems

Cancer

Type of relation if applicable

Diabetes

Type of relation if applicable

Heart Disease

Type of relation if applicable

High Blood Pressure

Type of relation if applicable

List all current Medications:

List all past Surgeries:

Do you smoke?

Yes

No

Number of children

Type of work you do:

Currently working?

Yes

No

If no, date last worked?

Hobbies:

Completion *

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