New Patient Registration

Today’s Date___________________ How did you hear about us?___________________________

Name_____________________________________________

Last First	Middle

(Complete Mailing)

Address_________________________________________________________________________**

Street Apt#	City State Zip

Date of Birth__________________ Age_______ M/F

Home Phone # (_____)______–_______** Work Phone # (_____)______–_______**

Cell Phone # (_____)______–_______** E-mail Address: ___________________________________**

Emergency Contact___________________ Relationship____________ Phone# (_____)______–_______

Employer_______________________ Occupation_________________ Phone# (_____)______–_______

Is this visit routine/accident/illness/other: _________________

If Accident (date) ___________Type_______________ To whom have you reported the accident to________________ Attorney Name___________________

RESPONSIBLE PARTY INFORMATION

Name (Guarantor)_________________________________________________________________

Last First Middle initial DOB

Relationship to Patient ___________________________

Address ____________________________________________ Phone# (_____)______–_______

Street City State Zip

Employer__________________________

Name of Insurance______________________ ID#_____________________Grp#_______________

Address_______________________________________________ Phone #(_____)______–_______

**Please notify our front office staff if there is an alternate address / phone number or form of communication** that you wish us to contact you by other than your listed information above.

I have read and understand that this alternative is available to me _____________________________ ________________

Signature Date

Staff Use Only

Chiropractic Coverage Yes No Effective Date of Policy______________________ Person spoken to______________ #Limit______________ $ Limit_______________ What is remaining________________ Adjustments _______________ (% OR $ amount) Examination _______________ (% OR $ amount) Re-examination _______________ (% OR $ amount) Co-Pay _______________ (% OR $ amount) Deductible _______________ (% OR $ amount) Amount met to date__________________ Acupuncture _______________ (% OR $ amount) Massage _______________ (% OR $ amount) PIP Verified (MVA, L&I) Correct Insurance Address___________________________________________________________________________

Acknowledgement and Understanding

Please initial each item below.

I hereby authorize Twisted Chiropractic to provide Chiropractic Services for me.

I understand and agree that regardless of insurance coverage, I am liable for any charges incurred as a result of services rendered to me at Twisted Chiropractic.

If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collections.

I hereby assign all chiropractic benefits, including major medical benefits to which I am entitled, Medicare, private insurance and all other health plans, to Twisted Chiropractic, 20714 SR305 Suite: 1F Poulsbo, WA 98370.

I authorize release of patient’s records to third parties requiring these records for determination of financial liability.

By signing this application I affirm under penalty that I have given true complete information.

Dated this _________day of _______________ 20_____.

____________________________________________________________

Patient Signature

__________________________________________________________________________________________________ Guarantor Signature	Relationship to Patient

AUTHORIZATION TO TREAT A MINOR

As a parent or legal guardian, I hereby authorize treatment for the following:

_____________________________________________ DOB _____________________

Patient’s full name

to any chiropractic treatment deemed advisable , if a parent or legal guardian is not available when the child is brought in for treatment.

This authorization will be effective as of _______________ and expires _______________.

Signature_____________________________________Witnessed by ____________________

(Parent or Guardian)