Patient Registration Form

Confidential Patient Information

Please fill in the form below
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
E-mail:
Birth Date

MonthDayYear
Sex:

MaleFemale
Social Security:
Marital Status:
Primary Care Physician MD name:*
Your primary MD's Phone Number:

Area CodePhone Number
MD Primary Care Office Address - if you don't know it skip this.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
We may need to contact your MD for records and to update them on your care here. We need your permission to do this.*

YESNO
Referred to our office by:*
If referred by a friend or doctor, who can we thank for recommending that you come see us? Full name if you know it. (If no one referred you just say "no one")*
referrer's name
Have you had Chiropractic Treatment in the past?*

YesNo
If you have seen a chiropractor in the past what worked best for you when you were under their care?
chiro that helped me
Was there anything that this "past" chiropractor or office staff did that you disliked?
What other chiro did that I did not care for
Work Information
Employer:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone Number:

Area CodePhone Number
Occupation:
Partner/Significant Other Information

skip if not applicable
Full Name:

First NameLast Name
Occupation:
In case of Emergency
Contact:

First NameLast Name
Phone Number:

Area CodePhone Number
Relationship:
I understand and agree to authorize the doctors at Life Enhancing Wellness Centers, LLC and/or the properly trained staff to administer examination procedures and treatments, as deemed necessary at that time:
Signature

Clear
Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Confidential Patient Information

Work Information

Partner/Significant Other Information

In case of Emergency