new patient form

City

State

Zip

City

State

Zip

Spouse or Guardian

Date of Birth

Home address

Emergency Contact

Insurance Assignment and Release: I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr. Brandon Cooper, D.C., all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. If insurance payments have not been received, or are denied by my insurance company, I agree to pay for services rendered within thirty (30) days of the written request by Cooper Chiropractic and Wellness, LLC. I further agree that I will pay all additional fees if a collection agency, or similar institution, is utilized to collect my payment. I authorize the use of my signature on all insurance submissions. Dr. Brandon Cooper, D.C. may use my health care information and may disclose such information the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
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How would you rate your overall Health?

What type of exercise do you do?

Indicate if you have any immediate family members with any of the following:

For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

List all prescription medications you are currently taking:

List all of the over-the-counter medications you are currently taking:

List all surgical procedures you have had:

What activities do you do at work?

What activities do you do outside of work ?

Have you ever been hospitalized?

if yes, why?

Have you had significant past trauma?

Anything else pertinent to your visit today?

Patient Signature

Date