Application for Treatment at the Little Rock Chiropractic Clinic

Little Rock Chiropractic Clinic, P.A.

Please print this form; fill out completely, and
fax to us at 501-371-0810, or bring to our location in person.

Name (first) __________________ (middle) _________________ (last) _______________________
Address ________________________________________________________________________
City ________________________ State __________________ Zip ________________________
Home Phone ( ) _________________ Office Phone ( ) _____________________
Date of Birth ___________________ Referred to our office by ____________________________
Social Security Number ________________________ Number of Children __________________

Please check or circle: Married - Single - Widowed - Divorced - Separated

Email Address _______________________________ Please select: Male - Female

Where are you employed? _________________________________________________________
Address ________________________________________________________________________
City _____________________________ State _______________________ Zip ______________

How will payment be made? (Please indicate)
Health Insurance - Worker's Comp. - Auto Insurance - Cash - Check - Credit Card


Name you nearest relative NOT living with you: Name ________________________________
Address ________________________________________________________________________ Phone __________________________________ Relationship ____________________________

Name SPOUSE'S nearest relative NOT living with you: Name _____________________________
Address ________________________________________________________________________ Phone __________________________________ Relationship ____________________________


Major complaint ('s) Please describe your major complaint's and describe the frequency and nature of your pain. For example: dull, sharp, constant, off and on, when standing, when sitting, etc. _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Please mark the exact location of your pain or symptoms on the diagrams below.
When did your condition first begin? _________________________________________________
How did your condition develop? ____________________________________________________
What caused it? _________________________________________________________________

Have you ever had this problem or similar problem before? ______ If yes, please explain: _____
_______________________________________________________________________________

Have you seen another chiropractic physician for this complaint? If yes, who? _______________
What was their diagnosis? _________________________________________________________

Have you seen another medical physician for this complaint? If yes, who? __________________
What was their diagnosis? _________________________________________________________

Is your condition getting better, worse, or staying the same? _____________________________
What makes your conditions worse? _________________________________________________
What makes your conditions better? _________________________________________________
Have you ever been involved in an automobile accident? _____ If yes, when and where? ______
_______________________________________________________________________________
What surgeries have you had? Include Date: _________________________________________
_______________________________________________________________________________ _______________________________________________________________________________
Please list drugs you now take: _____________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________
Please list vitamins, minerals, supplements, and/or herbs you now take:____________________ _______________________________________________________________________________ _______________________________________________________________________________ ____________________________________________________________________________
Please check if you have a history of the following:
Arthritis _____	Depression _____	Kidney Condition _____	Cancer ________
Epilepsy _____	Tuberculosis _____	Heart Condition _____	Scoliosis ______
Diabetes _____	Nervousness _____	Liver Condition _____	Headaches _____
High Blood Pressure_____ Sinus Condition_____ Stomach or Gastrointestinal Condition ____






Other Conditions or additional comments: ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________


CONFIDENTIAL CREDIT AND INSURANCE INFORMATION
Insurance Information: Name of Insured:__________________________________________
Insurance Company (primary) _____________________________________________________
Address ______________________ City ___________________ State _______ Zip __________
Telephone ( ) ____________________________________________________________
Policy group or Certification Number ________________________________________________
List any Secondary Insurance _____________________________________________________

Spouse's Information:
Name _________________________________________________________________________
Address ___________________________ (City, State, and Zip)_____________________________
Work Number ( ) ________________ Home Number ( ) ___________________
Employer ______________________________________________________________________
Address ___________________________ (City, state, and Zip)_____________________________
Date of Birth________________________ Social Security # _____________________________

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand and agree that the health and accident insurance policies are an arrangement between an insurance company and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and insurance forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. I also authorize the release of any needed information. I understand that if I suspend or terminate my care and treatment any fees for professional services rendered me will be immediately due and payable within 30 days. I also understand that I am giving my consent to be treated.
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Signature __________________________________________ Date ______________________

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DrRiley@LittleRockChiropractic.com
1100 W. 3rd Street
Little Rock, Arkansas 72201
phone - 501-371-0022
fax - 501-371-0810

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