Welcome to

Anderson Chiropractic Group

Please take the time to give us the following information so that we can have a thorough understanding of your health condition and
how we can serve you and meet your needs with excellence.

PATIENT INFORMATION
Today’s Date _____/_____/_____

Name _____________________________________________ Sex: M F Date of Birth _____/_____/_____

Address ___________________________________________________ City _____________________________

State __________________ Zip Code ___________ Home Phone Number _______________________________

Cell Phone __________________________________ E-Mail Address ___________________________________

Employer _____________________________________ Work Phone ____________________________________

S.S. Number ________________________ Referred By: ______________________________________________

Marital Status: Single Married Separated Divorced Widowed

Spouse Name _________________________________________ Date of Birth _____/_____/_____

Number of Children _____________ Ages __________________________________________________________

Emergency Contact Name _________________________________________ Phone _______________________

PAYMENT INFOMRATION
How will you be paying for your treatment today? Insurance Cash Check Credit Card

Do you have health insurance? Y N Company Name ___________________________________________

Are you the policy holder? Y N Policy Holder Name ____________________________________________

Are you covered by Medicare? Y N S.S. # ___________________________ D.O.B _____/_____/_____

Please give your insurance card to our staff at the front desk so that we can make a copy of it.

ACCEPTANCE OF UNCOVERED CHARGES

I understand that any insurance information provided by the staff at Anderson Chiropractic Group is provided as a
courtesy only and is in no way meant to construe a guarantee of benefit coverage. Although this office makes every
effort to obtain and provide accurate insurance coverage information, our information is fully dependent on that
which is provided by your insurer. We recommend that you contact your insurer directly to confirm your benefit
coverage. I acknowledge that it is possible that my insurance plan will not pay for all charges incurred in this office.
I acknowledge that I am responsible for any charges refused or discounted by my insurance company, worker
compensation plan, or automobile insurance, plus any additional late fees charged by Anderson Chiropractic Group.
Further, I agree to pay for any collections or legal charges incurred in the collection of these uncovered charges
should I fail to pay them within 30 days after invoiced or as agreed upon in a payment agreement plan with
Anderson Chiropractic Group.

Patient Signature __________________________________________________________Date _____/_____/_____

Parent/Guardian Signature __________________________________________________________