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New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

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 _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

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Office Hours

Our Regular Schedule

Office Hours

Monday:

Closed

Tuesday:

10:00 am-6:00 pm

Wednesday:

Closed

Thursday:

10:00 am-6:00 pm

Friday:

Closed

Saturday:

9:00 am-1:00 pm

Sunday:

Closed