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(320) 585-7246

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

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

Habits

Have you ever suffered from:

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Day
Monday8am-1pm2pm-5:30pm
Tuesday8am-1pm2pm-5:30pm
Wednesday8am-1pm2pm-5:30pm
Thursday8am-1pm2pm-5:30pm
Friday8am-1pm2pm-4pm
SaturdayBy Appt.Closed
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8am-1pm 8am-1pm 8am-1pm 8am-1pm 8am-1pm By Appt. Closed
2pm-5:30pm 2pm-5:30pm 2pm-5:30pm 2pm-5:30pm 2pm-4pm Closed Closed

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