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Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

Claim address on Insurance card


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

Have you ever:

Family History


Have you ever suffered from:

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Office Hours

Monday9am to 12:302:15pm to 5 pm
Wednesday9am to 12:302:15pm to 5 pm
Friday9am to 1:00
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
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2:15pm to 5 pm 7pm 2:15pm to 5 pm Closed Closed Closed

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