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Patient Data

Mailing Address

Current Complaints

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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

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Family History

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Office Hours

DayOpenClose
Monday8:00 am5:00 pm
Tuesday8:00 am5:00 pm
Wednesday8:00 am5:00 pm
Thursday8:00 am5:00 pm
Friday8:00 am5:00 pm
SaturdayClosedClosed
SundayClosedClosed
Day Open Close
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00 am 8:00 am 8:00 am 8:00 am 8:00 am Closed Closed
5:00 pm 5:00 pm 5:00 pm 5:00 pm 5:00 pm Closed Closed

Testimonial

I have benefited tremendously from the chiropractic care I received from Dr. Anderson.

John Doe
San Diego, CA

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