LAKZ10 Patient Registration

Patient Registration
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Insurance Information
Employer Phone Number
Please enter a valid phone number.
Occupation
Who is responsible for this account?
Relationship to Patient:
Name of Primary Insurance
Insurance Identification Number:
Insurance Type
Group Number
Individual Number
Cardholder Date of Birth

MonthDayYear
Date
In case of emergency please notify:

First NameLast Name
Please attach a photo of the FRONT side of your insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of your insurance card. You can use your cell phone to take the picture.

Cancelof
Assignment and Release*

I, the undersigned have insurance coverage with the above mentioned Insurance carrier(s) and assign directly to Lakewood Chiropractic Clinic., all medical benefits, if any - otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Lakewood Chiropractic Clinic., to release all information necessary to secure the payment of benefits. By checking this box I authorize the use of this electronic signature for my insurance submissions.
History and Physical
Who referred you to our office?
Who is your Primary Care Physician?
Reason for today's visit (CC):
Was there an injury?

YesNo
If so, Date of Injury:
Was it work related?

YesNo
Where does it hurt?
Does the pain radiate to anywhere else?
Describe the pain (check all that apply)

ConstantCome & GoesSharpDullAchyBurningNumbnessOther
How severe is your pain:

1

2

3

4

5

6

7

8

9

10

1 is Very Mild, 10 is Very Severe
How long has it hurt?
Any other symptoms?
What makes it better?
What makes it worse?
Have you had any of the following treatments:
Physical Therapy:

YesNo
Length
Cortisone Inj.:

YesNo
Medications:

YesNo
Chiropractic:

YesNo
Type
Pain Clinic:

YesNo
Length
Other:

YesNo
Explain:
Medical Problems
Cancer
Type of relation if applicable
Diabetes
Type of relation if applicable
Heart Disease
Type of relation if applicable
High Blood Pressure
Type of relation if applicable
List all current Medications:
List all past Surgeries:
Do you smoke?

YesNo
Number of children
Type of work you do:
Currently working?

YesNo
If no, date last worked?
Hobbies:
Completion*

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