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Welcome to Kicos Chiropractic Center Please fill this form out completely. If you have any questions, just ask the front desk receptionist. Thank you. 1. PERSONAL INFORMATION Today’s Date: / / File #: Name (First/Last): What do you prefer to be called? Date of Birth: / Check One: ( ) Male ( ) Female / Social Security #: Home Address: City, State, Zip: Home Phone #: Alternate #: Doctor or Friend who referred you to Kicos Chiropractic: Occupation: Work Phone #: Employer: How long have you worked there? Employer’s Address: Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Separated ( ) Widowed Doctor’s Notes Spouse’s Name: 2. INSURANCE INFORMATION Insurance Company: Phone #: ID/Policy/Plan #: Group #: Claims Address: Relation to Insured: Insured’s DOB: Insured’s Name: / / Social Security #: Insured’s Employer: Please inform front desk receptionist if you have a second insurance source. 3. REASON FOR VISIT Have you ever been treated by a Chiropractor before? ( ) Yes ( ) No If so, please explain: This visit is due to (please circle one or more): Work / Sports / Auto / Trauma / Chronic Pain Explain what happened: Describe the pain and its location: When did the condition begin? Is the condition getting worse? ( ) Yes ( ) No ( ) Constant ( ) Comes and Goes Is the condition interfering with your (please circle one or more): Work / Sleep / Daily Routine If so, please explain: Have you been treated by a Medical Physician for this condition? ( ) Yes ( ) No If so, when and by whom? 4. MEDICAL HISTORY Are you taking any of the following medications? ( ) Nerve Pills ( ) Pain Killers, including Asprin ( ) Muscle Relaxants ( ) Blood Thinners ( ) Tranquilizers ( ) Other/s: ( ) Insulin ( ) Stimulants Do you now have, or have you ever had any of the following diseases/medical conditions? Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N Heart Attack / Stroke Congenital Heart Defect Alcohol / Drug Abuse HIV+ / AIDS Frequent Neck Pain High / Low Blood Pressure Severe / Frequent Headaches Fainting / Seizures / Epilepsy Diabetes / Tuberculosis Lower Back Problems Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N Heart Surgery / Pacemaker Mitral Valve Prolapse Venereal Disease Shingles Emphysema / Glaucoma Psychiatric Problems Kidney Problems Sinus Problems Difficulty Breathing Artificial Bones / Joints Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N Heart Murmur Artificial Valves Hepatitis Cancer Anemia Rheumatic Fever Ulcers / Colitis Asthma Chemotherapy Arthritis Please list any other serious medical conditions you have or ever had: Please list anything you are allergic to: List previous surgeries / treatments with dates: List any past serious accidents with dates: Family medical information that may be relevant: Do you smoke? ( ) No ( ) Yes / How much? Are you wearing: ( ) Heel Lifts ( ) Sole Lifts How Long? ( ) Inner Soles ( ) Arch Supports What is the age of your mattress? Women: Are you taking birth control? ( ) Yes ( ) No Is it comfortable? ( ) Yes ( ) No Are you pregnant? ( ) No ( ) Yes / How far along? 5. ACCOUNT INFORMATION Name of person ultimately responsible for account: Relation: Billing Address: Social Security #: Work Phone #: Payment Method: ( ) Cash ( ) Check ( ) Credit Card ( ) Insurance – Please give the receptionist your insurance card to copy ( ) I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered, if offered at this office. ▪ We invite you to ask us any questions regarding our services. The best health services are based on a friendly, mutual understanding between the provider and the patient. ▪ Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the office manager. If account is not paid within ninety(90) days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees and any other expenses incurred in collecting your account. ▪ I am fully responsible for any expenses not paid by my insurance carrier, including all copayments and any coinsurance amounts. ▪ I authorize the provider to release any information required to process insurance claims. ▪ I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand that it is my responsibility to inform this office of any changes in my medical and insurance status. Signature: Date: