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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:

Exclusive Offer

New Patients are eligible for a Free Initial Consultation.

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

Office Hours

DayMorningAfternoon
Monday8:30am - 11:30 am2pm - 6pm
Tuesday8:30am - 11:30 am2pm - 6pm
Wednesday8:30am - 11:30 am2pm - 6pm
Thursday8:30am - 11:30 am2pm - 6pm
Friday8:30am - 12:00 pmClosed
SaturdayClosed
SundayClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30am - 11:30 am 8:30am - 11:30 am 8:30am - 11:30 am 8:30am - 11:30 am 8:30am - 12:00 pm Closed Closed
2pm - 6pm 2pm - 6pm 2pm - 6pm 2pm - 6pm Closed

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