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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:

THIS ---->https://amfamilyspinecom.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday10:15-12:153-6
TuesdayClosed3-6
Wednesday10:15-12:153-6
Thursday8:30-10:303-6
Friday9:00-10:00Closed
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
10:15-12:15 Closed 10:15-12:15 8:30-10:30 9:00-10:00 Closed Closed
3-6 3-6 3-6 3-6 Closed Closed Closed

Testimonial

Dr. Clark and his staff are great. He fixed me up 4 years ago and I continue to see him twice a month, it's a way of life and would never give it up. Thank you American Family Spine and Health.

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