PhoenixChiropractor.com

602 954-2447

Confidential Patient Information
Personal Information
Occupation & Employment
Chiropractic History
Automobile Accident
Reason for Visit & Symptoms

Click on the areas where you feel pain or discomfort. Selected areas will be included in the form submission.

Body diagram
Front view Side view Back view
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Health History — Past 6 Months

Check any of the following you have experienced in the last six months:

Payment Policy
Due to changes in health insurance fees, patient self billing has become a much more cost effective way for you, the patient, to get reimbursement for your care. Self billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.

All charges are due when services are rendered.
Authorization & Signature

I authorize this Chiropractic Office to render necessary services to me and understand that I am responsible for all charges incurred.

Thank You For Allowing Us To Serve You!