Toledo Chiropractic Registration Form

Last Name
First Name
Address
City
State
ZIP
E-mail
Birth Date
Sex



Social Security No.
Employer Name
Work Phone
Please list the name of anyone to whom we may release your medical information
Names to be released

PRIMARY HEALTH INSURANCE COVERAGE

Insurance
Insured'd Employer
Insured's SS#
Relationship to patient
Assignment of Benefits/Authorization for Treatment I herby authorize treatment and authorize the provider of medical services to release information for these services to my insurance carrier for payment. I further authorize that payment of benifits be made to the provider on my behalf. I understand that I am fully respnsible for all charges incurred, regardless of my insurance status, for profrssional services rendered
  • Signature of patient:________________________________
  • Date:__________________