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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:

THIS ---->https://raefchiropracticcom.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday8:30am5:30pm
Tuesday8:30am5:15pm
Wednesday8:30am12:00pm
Thursday8:30am5:30pm
Friday8:30am4:30pm
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30am 8:30am 8:30am 8:30am 8:30am Closed Closed
5:30pm 5:15pm 12:00pm 5:30pm 4:30pm Closed Closed

Office will be closed Friday, Dec 23 through Tuesday Dec 27.
We will open on Dec 28, 29 and 30.

New Year's hours:
Office will be closed Monday Jan 2, 2017.
We will open on Tuesday Jan 3, 2017.

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