You are using an outdated browser. Please upgrade your browser to improve your experience.
Home | New Patient Center | New Patient Health History Form
In order to provide you the best possible wellness care, please complete this form
Nature of Injury
*If an auto accident, please provide:
Name of the Insured _____________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's signature _______________________________________________
Spouse's or guardian's signature __________________________________