MEDICATION, HERBS, SUPPLEMENTS
PAST HEALTH HISTORY
Please report any past health conditions that may affect a proper diagnosis.
Review of Systems
(check all that apply)
Consent for Treatment and Insurance Authorization
I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of Chiropractic at In Motion Sports and Family Chiropractic. I hereby assign benefits and I Understand that payment is due as services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company(excluding contractual allowance).if, after 60 days, insurance payment has not been received. I understand that the charges are my responsibility and payable immediately. Additionally, I consent to treatment as deemed necessary by the Doctor of Chiropractic at In Motion Sports and Family Chiropractic