Baker Chiropractic & Acupuncture
 Confidential Patient Information

Welcome to our office!

The following is needed for our files so we can better serve you as our patient. Please fill in all portions of the form. If you need any help, please ask the receptionist.

Date of Information ___________________
Were you referred to a certain doctor at this office? _____ If so, which Doctor?__________
Who referred you to this office? ________________________
Is your visit to this office in reference to an accident? ______________

Patient Data
Name _______________________________________
Address ______________________________City _____________________________

State ____________   Zip______________ Social Security Number ___________________
Age _____ Birth date _______________ Marital Status ________ Number of Children _____

Home phone (______) _____________________
Work phone (_____) ______________   Cell Phone (______) ______________

Email Address _________________________________________

Occupation _______________________________________ 

Employed by ______________________________________
Name of Spouse or Significant Other__________________________

Their Occupation _____________________
Spouse’s or Significant Other's Social Security Number_________________

Spouse's or Significant Other's Employer ________________________
Name of Nearest Relative _____________________________________

Phone Number (_______) _________________________
Relationship to Patient ____________________________

Briefly Describe Symptoms ______________________________________________________________
How long have you had these symptoms? _________________________________________
Date of Last Physical Exam _______________________________________________
What operations have you had? ___________________________________________________________
Serious Illnesses _______________________________________________________________________
List other Doctors seen for this/ these conditions______________________________________________ ______________________________________________________________________________

What medications or drugs are you taking?_____________________________________________________
___________________________________________________________________________

Supplements or over-the-counter medications?_________________________________________________ ______________________________________________________________________

Office Policy requires payment at the time of service. Payment arrangements must be made on the first visit. We accept Cash, Check, Visa MasterCard, Discover and Debit as payment.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that any amount authorized to be paid directly to this office will be signed over to me or credited to my account on receipt. I permit this office to endorse co-issued remittances for the conveyances of credit to my account. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Patient’s Signature __________________________________________Date________________

If Yours Is an Accidental Injury, Please inform the receptionist.