ROSALES CHIROPRACTIC CLINIC - REQUEST AN APPOINTMENT

We know you have many choices when choosing a Chiropractor in San Antonio, TX, so we have made requesting an appointment a simple process via our Web site. Simply fill out the form below and we will contact you with a confirmation.

PATIENT INFORMATION
 
DATE:
SS/HIC/PATIENT ID NUMBER:
PATIENT LAST NAME:
PATIENT FIRST NAME:
PATIENT MIDDLE INITIAL:
ADDRESS:
CITY:
STATE:
ZIP:
EMAIL:
SEX: M F
BIRTHDATE:
 
MARRIED WIDOWED SINGLE MINOR
SEPERATED DIVORCED PARTENERED FOR   YEARS
   
OCCUPATION:
PATIENT EMPLOYER/SCHOOL:
EMPLOYER/SCHOOL ADDRESS:
EMPLOYER/SCHOOL PHONE:
SPOUSE'S NAME:
BIRTHDATE:
SS NUMBER:
SPOUSE'S EMPLOYER:
WHO REFFERED YOU:
   
PHONE NUMBERS
 
HOME PHONE:
CELL PHONE:
BEST TIME AND PLACE TO REACH YOU:
BEST TIME TO REACH YOU:
   
IN CASE OF EMERGENCY, CONTACT  
   
NAME:
RELATIONSHIP:
HOME PHONE:
WORK PHONE:
   
INSURANCE
 
WHO IS RESPONSIBLE FOR THIS ACCOUNT:
RELATIONSHIP TO PATIENT:
INSURANCE COMPANY:
GROUP NUMBER:
IS THE PATIENT COVERED BY ADDITIONAL INSURANCE:
SUBSCRIBER'S NAME:  
BIRTHDATE:  
SOCIAL SECURITY NUMBER:
RELATIONSHIP TO PATIENT:
INSURANCE COMPANY:  
GROUP NUMBER:  
   
ASSIGNMENT AND RELEASE  
   
I CERTIFY THAT I, AND/OR MY DEPENDANT(S), HAVE INSURANCE COVERAGE WITH
(NAME OF INSURANCE COMPANY )   AND ASSIGN DIRECTLY
TO DR. ROSALES ALL INSURANCE ALL INSURANCE BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR MY SERVICES RENDERED. I UNDERSTAND THAT I AM FINALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE FOR THE PURPOSE OF OBTAINING PAYMENT FOR SERVICES AND DETERMINING INSURANCE FOR THE PURPOSE OF OBTAINING PAYMENT FOR SERVICES AND DETERMINING OR THE BENEFITS PAYABLE FOR RELATED SERVICES. THIS CONSENT WILL END WHEN MY CURRENT PLAN IS COMPLETED OR ONE YEAR FROM THE DATE SIGNED BELOW.
   

E-Signature of Patient, Parent, Guardian, or Personal Representative
   
ACCIDENT INFORMATION
 
IS YOUR CONDITION DUE TO AN ACCIDENT? Yes No
DATE:
TYPE OF ACCIDENT:  
AUTO WORK HOME OTHER
   
TO WHOM HAVE YOU MADE A REPORT OF YOUR ACCIDENT?
AUTO INSURANCE EMPLOYER WORKER COMP. OTHER
   
ATTORNEY NAME (IF APPLICABLE)
   
PATIENT CONDITION
 
Name:
Address:
Phone Number:
Best Time To Reach You:
   
Requested Appointment  
   
Date
Time
   
HEALTH HISTORY
 
AIDS/HIV
 Yes No ALCOHOLISM
 Yes No
Allergy Shots
 Yes No ANEMIA
 Yes No
Anorexia
 Yes No APPENDICITIS Yes No
Arthritis Asthmas
 Yes No BLEEDING DISORDERS
Yes No
Breast Lump
 Yes No Bronchitis
 Yes No
Bulimia
 Yes No Cancer
 Yes No
Cataracts Yes No Chemical Yes No
Dependency
 Yes No Liver Disease
 Yes No
Measles
 Yes No Migraine Headaches
 Yes No
Miscarriage
 Yes No Mononucleosis
 Yes No
Multiple Sclerosis
 Yes No Mumps
 Yes No
Osteoporosis
 Yes No Pacemaker
 Yes No
Parkinson's Disease
 Yes No Pinched Nerve
 Yes No
Pneumonia
 Yes No Polio
 Yes No
Prostate Problem Yes No Prosthesis
 Yes No
Psychiatric Care
 Yes No Rheumatoid Arthritis
 Yes No
Rheumatic Fever
 Yes No Scarlet Fever
 Yes No
Stroke
 Yes No Suicide Attempt
 Yes No
Thyroid Problems
 Yes No Tonsillitis
 Yes No
Tuberculosis
 Yes No Tumors, Growths
 Yes No
Typhoid Fever
 Yes No Ulcers
 Yes No
Vaginal Infections
 Yes No Venereal Disease
 Yes No
Whooping Cough
 Yes No Other
   
EXERCISE
 
NONE
 MODERATE
DAILY
 HEAVY
   
WORK ACTIVITY
 
SITTING

 STANDING
LIGHT LABOR

HEAVY LABOR
   
HABITS
 
SMOKING
 PACKS PER DAY

ALCOHOL
 DRINKS PER WEEK
COFFEE/CAFFINE
 CUPS PER DAY
HIGH STRESS LEVEL
REASON
ARE YOU PREGNANT? DUE DATE
   
INJURIES YOU HAVE HAD
 
 
DESCRIPTION
 
DATE
FALLS
  
HEAD INJURIES
 
BROKEN BONES
 
DISLOCATIONS
  
SURGERIES  
   
MEDICATIONS
 
   
PHARMACY NAME:
PHARMACY PHONE:
   
ALLERGIES
 
   

VITAMINS/HERBS/MINERALS
 
   
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Rosales Chiropractic Clinic       |      E-mail: info@rosaleschiropractic.com     |      Contact: 210-674-2700

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