Ninety Nine Street Chiropractic Clinic

Patient Name:__________________________________________

Address:______________________________________________

Sex:________ Birthdate:______________

Home Phone: __________________________________________
Cell Phone:____________________________________________

Social Security number: ___________________________________

Patient Employed: Y or N

Business Address: ______________________________________

Occupation: ___________________________________________

Business Phone: ________________________________________

Major Compliant: _______________________________________

Have you seen anyone else for this condition? Y or N

Doctor’s Name: ________________________________________

Address: ______________________________________________

City, State and Zip Code:__________________________________ 

Insurance Information:  

Name of Insured:________________________________________

Relationship to you:______________________________________

Insurance Company:_____________________________________

Phone Number:_________________________________________

Policy Number:_________________________________________

Group Number:_________________________________________ 

Signature_______________________________  Date______________

By completing this form, I am stating that I fully understand that I am directly and fully responsible for services rendered

to me. I further understand that payment for services in not contingent on any settlement, judgment or verdict by which

I may eventually recover. The clinic will bill one insurance carrier for me. However, I clearly understand and agree that all

services rendered to me are charged directly to me and that I am personally responsible for payment.