THE CHICAGO BODY WORKS
New Patient Information
Name: _____________________________________________ Social Security# _____/______/______
Address: _____________________________ City: ______________ State: ______ Zip: ____________
Telephone: ________________ Alternate Phone:_______________ E-Mail:_______________________
Birth date: _________________ Marital Status: M S W D # Children ____ Student: __Full __Part-time
Occupation: ___________________ Employer: _____________________________________________
Describe Daily Activites:________________________________________________________________
Contact Name: __________________ Contact Phone: ______________ Referred by:_______________
Insurance Information
Insurance Company: ___________________ Member ID:__________________Group # _____________
Name of Policy Holder: _______________________________________________ D.O.B.____________
Ins. Address: ________________________________________________________________________
Health-related Information
Are you here due to an accident? (Y or N)_____ Illness? (Y or N)_____ Other: _____________________
Have you had previous Chiropractic care? (Y or N)_____ If so, where and when?____________________
Do you suffer from any major health conditions?______________________________________________
Medications you are currently taking:_______________________________________________________
Office Policies
Your appointment is reserved for you. We ask that you honor the late-cancellation policy to avoid a
charge of $60. ____________(please initial)
I clearly understand and agree that all services rendered to 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 to me will be immediately due and payable. Any
amount which remains past due beyond 60 days notice will be charged to my credit card.
Patient’s Signature: ___________________________________________ Date: __________________
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