Application for Care Application for Care Patient Information First Name * Last Name * Phone Number * Can you receive text alerts to this number? * Yes No This is solely for sending a text reminder the day before your appointment; your phone number will not be used for marketing purposes. Cell Phone Carrier Home Phone Work Phone Email * Receive email alerts? * Yes No Street Address Line #1 * Street Address Line #2 City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Birth Date * Marital Status * Single Married Widowed Divorced Do you have children? Yes No Number of Children Employer If unemployed, skip this field. Occupation Employer Address Line #1 Employer Address Line #2 Employer City Employer State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employer Zip Code Spouse or Parent Information First Name Last Name Birth Date Occupation Employer Employer Street Address Line #1 Employer Street Address Line #2 Employer City Employer State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Employer Zip Code In Case of Emergency First Name * Last Name * Phone * Street Address Line #1 * Street Address Line #2 City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Health Insurance Information In order to make your visit more pleasant, it is helpful for you to provide your health insurance information. Would you like us to verify your health insurance coverage? * Yes No Primary Insurance Company Name * Insurance Phone Number (found on back of card) Member ID# * Do you have Medicare? * Yes No Do you have Medicaid? * Yes No Do you have secondary insurance coverage? Yes No Secondary Insurance Company Name Insurance Phone Number (found on back of card) Member ID# Payment Method * Cash/Check Credit Card Worker's Compensation Automobile Insurance Policy I (we) agree to pay for service rendered to the above mentioned patient as the charge is incurred. I understand and agree that health & accident insurance policies are an arrangement between an insurance carrier and myself that I am personally responsible for payment of any and all services covered or not covered. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered me will immediately due and payable. By entering my initials below I understand that I accept the above terms. Additional Information Referred to our office by: Is your condition due to an auto accident or workplace injury? * Yes No Date of Accident Type of Accident Auto Work/On Job At Home OtherOther Have you ever been in an auto accident? * Past Year Past 5 Years Over 5 Years Never Your Initials * reCAPTCHA
