New Patient Form Confidential Patient InformationName* First Last Home PhoneWork/Cell PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth Marital StatusMSDWPGenderAgeEmail Address* OccupationEmployerWork Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Spouse's Name First Last Number of ChildrenWho may we thank for referring you to our office?Emergency ContactPhoneMay we contact this person in case of an emergency?YesNoHave you ever had chiropractic care before?YesNoDate Is this injury related to:Auto AccidentDate LocationDue to changes in health insurance fees, patient self-billing has become a much more cost-efficient way for you, the patient, to get reimbursement for your care. Self-billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.Please check here if you would like health care receipts for your visits.Method of paymentCheckCashCredit CardAll charges are due when services are rendered.Why Chiropractic?People go to Chiropractic for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program. Please select the type of care that best meets your needs. Relief Care: Relief Care is care that is necessary to get rid of your symptoms or pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, but not fixing the leak. Corrective Care: Corrective Care differs from Relief Care in that its goal is to get rid of the symptoms or pain while correcting the cause of the problem. Corrective Care varies in the length of time, but it is more lasting. Authorization* I authorize Walker Family Wellness and Dr. Craig Walker, DC to render necessary services to me and I understand that I am responsible for all charges incurred. Patient Signature*Date* Parent or Legal Guardian Authorizing Care First Last What hurts and how long has it hurt? When do you think these problems originally started? List other Chiropractic or Medical Doctors you have consulted for these conditions: Check any of the following you have had in the past six months: Headaches Sinus Congestion/Allergies Vision Problems Ear Aches Dizziness Heart Problems Lung Problems/Congestion Blood Pressure Problems Ankle Swelling Prostate/Sexual Dysfunction Menstrual Cycle Dysfunction Numbness Frequent Nausea/Vomiting Abdominal Cramps Constipation Diarrhea Poor/Excessive Appetite Excessive Thirst Painful/Excessive Urine Discolored Urine Diabetes Cancer Are you pregnant?YesNoUnsureI acknowledge that:* Select All I have read and understand the WFC Statement of Clinical Objectives. I have read and understand the HIPPA Notice of Privacy Practices. I have read and understand Dr. Walker's Explanation of Chiropractic Treatment and give my full consent to treatment. Patient's Signature*Patient Name* First Last Date of Birth* Thank You For Allowing Us To Serve You!CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
