Pre-register AND set up your appointment.  Save time by completing your patient information all at the convenience of home or work.  After registration below, request date and time for appointment and a health care professional will call to confirm your appointment.

"Submit" this form via email OR complete,  print and bring it in with you !!
Patient Name   Male      Female
Birth date SS#   
Address  City  State     Zip 
Home Phone     Work Phone  Referred by
Email Address Occupation
Employer Name Children  Yes     No
Address  City  State     Zip 
Status Minor    Single    Married   Separated  Divorced  Widowed
Spouse's Name How Many Children 
Company Name Phone  
Company Address State     Zip 
Group or Policy #  Insured's SS#  
Insured's Name Relation  
Insured's Employer  
* Please inform front desk of 2nd Insurance source
     
Visit is a result of            
Please describe pain & its location   
When did condition begin ?  Condition getting worse ? Y   N      Constant
If condition is interfering with your work, sleep or daily routines, please explain:
Have you had similar conditions in the past ? Yes       No         If yes please explain:
Have you been treated by a Medical Physician for this condition ? Yes       No         Where ?
Have you ever been treated by a Chiropractor before ? Yes       No   
If so, by whom ? Phone #  
Who should we contact ? Relation            
Home Phone #                Work Phone #   
Who is your Medical Doctor?   Phone #            
   
Are you taking any of the following medications : Nerve Pills   Pain killers (including aspirin)  Insulin
Muscle relaxers        Stimulants    Blood Thinners    Tranquilizers       Other
Do you have or ever had any of the following diseases or conditions ?
Yes  No Heart Attack/Stroke

Yes  No

 Heart Surg/Pacemaker   Yes  No Heart Murmur
Yes  No Congenital Heart Defect Yes  No Mitral Valve Prolapse   Yes  No Artificial Valves
Yes  No Alcohol/Drug Abuse Yes  No Venereal Disease   Yes  No Hepatitis
Yes  No HIV+ / Aids Yes  No Shingles   Yes  No Cancer
Yes  No Frequent Neck Pain Yes  No Emphysema/Glaucoma   Yes  No Anemia
Yes  No High/Low Blood Pressure Yes  No Psychiatric Problems   Yes  No Rheumatic Fever
Yes  No Severe Headaches Yes  No Kidney Problems   Yes  No Ulcers / Colitis
Yes  No Fainting/Seizures/Epilepsy Yes  No Sinus Problems   Yes  No Asthma
Yes  No Diabetes/ Tuberculosis Yes  No Difficulty Breathing   Yes  No Chemotherapy
Yes  No Lower Back Problems Yes  No Artificial Bones/Joints Yes  No Arthritis
Please list anything that you may be allergic to      :
List previous surgeries / treatments with dates     
List any past serious accidents with dates     
Family Health History     
Do you : Take Supplements or Vitamins Yes   No
Exercise ? Yes   No
Special Diet ? Yes   No How Long ?
Smoke ? Yes   No How Long ?
What is the age of your mattress   Comfortable   Yes   No
Women:  Taking Birth Control ? Yes   No Pregnant ?  Yes   No
Yes/  How long  Nursing ?  Yes   No
   
Name   Relation  
Billing Address Billing Address         
City      State          Zip 
SSN #   D.L. #  
Work Phone   Payment method: Cash     Check  CrCard
   
Requested Date Requested Time 

A member of River Ridge Chiropractic will confirm this appointment with you over the phone or return email !

                            

► We invite you to discuss with us any questions regarding our services.  The best health services are based on a friendly, mutual understanding between provider and patient.
► Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager.  If account is not paid within 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 authorize the staff to perform any necessary services needed during diagnosis and treatment.  I also authorize the provider and or managed care organization 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 it is my responsibility to inform this office of any changes to the information I have provided. 

   

__________________________

  Date____/____/____

Signature

 Adult    Parent     Spouse

"Submit" this form via email OR complete and print and bring it in with you !!