Print this form, fill it in and fax to 714.841.2564. Call to make an appointment for a free consultation and assessment.

Today's Date__________________

PATIENT INFORMATION

Name:_____________________________________

Home Address:______________________________

City:___________________ ST:____ ZIP:________

Home Phone#:______________________________

Cell Phone #:_______________________________

Sex: Male Female

Birthdate:________________ Age:___________

Social Security #:____________________________

Referred by:________________________________

SPOUSE

Name:_____________________________________

Birthdate:______________ SS#:_______________

Employer Name:_____________________________

Occupation:_________________________________

Address:___________________________________

City:________________ ST:________ ZIP:_______

Phone #:___________________________________

INSURANCE INFORMATION

Who is responsible for this account?______________

Relationship to patient:_________________________

Group# (Plan, Local, or Policy#):_________________

Is patient covered by additional insurance? Yes No

Subscriber's Name:____________________________

Birthdate:_______________ SS#:________________


ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent)
have insurance coverage with___________________
and assign directly to Dr._______________________
all insurance benefits, if any, otherwise payable to me
for services rendered. I understand that I am finan-
cially responsilble for all charges whether or not paid
by insurance. I hereby authroize the doctor to release
all information necessary to secure the payment of
benefits. I authorize the use of this signature on all
insurance submissions.

___________________________________________
Responsible party signature

___________________________________________
Relationship and Date signed

IN CASE OF EMERGENCY, CONTACT:

Name:__________________________________ Relationship:________________________________________

Home Phone:_______________________________ Work Phone:_____________________________________

EMPLOYER

Company Name:_____________________________

Occupation:_________________________________

Address:___________________________________

City:__________________ ST:_____ ZIP:________

Phone:_____________________________________

ACCIDENT INFORMATION

Is condition due to an accident? Yes or No

Date of accident:_____________________________

Type of accident: Auto Work Home Other

To whom have you made a report of your accident?
     Auto Insurance   Employer     Workers Comp     Other 

Attorney Name (if applicable)_____________________

PATIENT CONDITION

Reason for visit (please circle):    work     sports   auto    trauma   chronic

What happened?_____________________________________________________________________________

When did your symptons begin?_________________________________________________________________

Is this condition getting worse?  (please circle)      Yes      No    Constant     Comes and goes

Please describe the pain and its location:_________________________________________________________

Is this condition interfering with your (please circle): work, sleep or daily routine

Have you had this or similar conditions in the past?   (please circle)      Yes     No

If so, please explain:_________________________________________________________________________

HEALTH HISTORY

Are you pregnant?   Yes    No

Are you taking any of the following medications? (please circle all that apply)

Nerve Pills     Pain Killers (including aspirin)     Muscle relaxers     Stimulants     Blood thinners     
Tranquilizers     Insulin     Other(s)___________________________

Do you eat, drink, or use? (please circle all that apply)

Alcohol     Carbonated beverages     Chew Tobacco     Cigarettes     Coffee

Please list any other serious medical conditions(s) you have or ever had:________________________________

__________________________________________________________________________________________

Please list anything that you may be allergic to:____________________________________________________

List previous surgeries/treatments with dates:_____________________________________________________

List any serious accidents with dates:____________________________________________________________

Do you smoke (please circle):    Yes       No       How much?_________________   How long?______________

Are you wearing (please circle):       Heel lifts  Sole lifts  Inner soles  Arch supports    

SHOW US WHERE IT HURTS

Please mark area(s) of injury of discomfort as shown below in the example. Indicate the degree of pain using a
scale of 1 (discomfort) to 10 (extreme pain).

Guarantee:
If we accept you as a patient, we fully expect you to obtain results. In fact, we guarantee results! If you do not receive results within five visits, or if for any reason you are not pleased with your treatment, we will give you a full refund. . . no questions asked, no catches, no gimmicks.

I am interested in the guarantee: (circle one)         Yes       No