New Client Form                                                                                              Word Doc

Name                         Today's Date      

Address           

City                          State             Zip      

Home Phone            Work            Cell   

Email                  

Date of Birth             Age                                    Gender     - F M

Occupation               Employer   

Responsible Party if Minor     Relationship   -Select One- Parent Guardian Other

Reason Requesting Treatment

Accidents/Surgeries

Medications/Allergies

Other Pertinent Information

I understand:

1)  that this office does not bill insurance companies,

2)  that my account with this office is my responsibility,

3)  that it is essential that I/my child remain under the care of a qualified medical doctor,

4)  that this office does not provide medical care.