New Patient Forms - Young Harris Chiropractor

New Patient Intake Form

Address: 1615 Highway 17 Suite 2
Young Harris, GA 30582
Tax ID: # 84-4932428
Phone: (762) 349-1777

Last Name

First Name

Mailing Address

Home Phone

Work Phone

Cell Phone

Date of Birth

SSN

Email Address

Employer/Occupation

Parent or Guardian (If patient is a minor)

Medical Provider

Referring Provider (If applicable)

INSURANCE INFORMATION
We need a copy of your insurance cards/ID card. Please fill out completely.

Primary Insurance

Address

Phone #

Group #

ID #

Date of Worker's Comp Injury

Date of Vehicle Accident

Insured's Name

Relation to Patient

Insured's Name

Insured's employer if applicable

Insured's Phone Number

Secondary Insurance

Address

Insured's Name

Relation to Patient

DOB

Insured's Employer (If applicable to plan)

Phone #

I understand all payments for treatment received are my responsibility. I hereby acknowledge the release of any information to my insurance company(s) that may be required to process a claim on my behalf.

I hereby authorize my insurance company(s) to remit payment for any medical benefits due, directly to Trinity Chiropractic. This authorization shall expire in one year, or upon my written notice.