JANWAY CHIROPRACTIC

PATIENT INFORMATION SHEET 

PATIENT:

Last Name:____________________________First  Name:_______________________Middle________

Gender:  M   F  Date of Birth:___________     Age_______SS#__________________________________

Address_____________________________________________________________________________

City_____________________________________State_________________________Zip____________

Home Phone______________________________Alternate phone______________________________

Employer Name___________________________________Occupation__________________________

Employer  address__________________________________Phone _____________________________

City____________________________________State_________________________Zip_____________

SPOUSE OR GUARDIAN

Last Name________________________________First Name____________________Middle__________

Employer Name_________________________________________Work Phone_____________________

Date of Birth______________  SS#_________________________________________________

EMERGENCY:  Name and address of nearest relative or friend not living with you.

Last Name_______________________________First Name____________________Middle___________

Home Phone_____________________________Work/Alternate  Phone__________________________

Relation to patient:_____________________________________________________________________

INSURANCE

Insurance Company____________________________________________________________________

Insureds Name__________________________________________Policy/ID #_____________________

Insurance  Company____________________________________________________________________

Insureds Name__________________________________________Policy/ID#______________________

Wiorkers Compensation Insurance________________________________________________________

Insured’s Name__________________________________________Policy/ID#______________________

RESPONSIBLE PARTY:  Complete this section if you are not the patient but are responsible for the bill.

Responsibility Party___________________________________Relationship to Patient_______________

Home Address________________________________________City_____________________State_____

Home Phone #__________________________________Alternative/Work ________________________

Employer Name________________________________________________________________________

I REQUEST SERVICES AND I GIVE PERMISSION FOR DR. JANWAY AND HIS STAFF TO ADMINISTER TREATMENT.

SIGNATURE:  (Patient, Parent, Legal Guardian or Responsible Party.

X_____________________________________________________

I received “Privacy Notice to Patients”.

X_____________________________________________________

            (Please turn over and read and sign the back of this page)

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