Dr. Gary T. Scardino | 319 South State Street, Newtown, Pa 18940 | 215-860-7275

Scardino Family Chiropractic Center

Thank you for choosing our practice for your chiropractic needs. Please complete this form in link. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

Patient Information

Name

Date

SS/HIC/Patient ID#:

Address

Street Address

City

State

ZIP Code

Sex:

Male

Female

Date of birth

Email *

Home Phone:

Cell Phone:

Work Phone:

Do you prefer to receive calls at:

Partnered for ____ years

Patient Employer/School:

Occupation:

Employer/School Address:

State

City

Zip Code

Spouse/Parent’s Name:

Employer:

Work Phone:

Whom may we thank for referring you to us?

Person to contact in case of emergency:

Phone:

Responsible Party

Name of the person responsible for this account:

Relationship to Patient:

Phone:

Address:

City:

State:

Zip Code:

Name of Employer:

Work Phone:

Insurance Information (Please bring your insurance card to office)

Name of Insured:

Relationship to Patient:

Birthdate:

Social Security#:

Date Employed:

Name of Employer:

Work Phone:

Address:

City:

State:

Zip:

Insurance Co.:

Group#:

Employer#:

Insurance Co. Address:

City:

State:

Zip:

How much is your deductible?

How much have you used?

Max. annual benefit?

DO YOU HAVE ADDITIONAL INSURANCE?

Yes

IF YES, PLEASE COMPLETE THE FOLLOWING:

Name of Insured:

Relationship to Patient:

Birthdate:

Social Security#:

Date Employed:

Name of Employer:

Work Phone:

Address:

City:

State:

Zip:

Insurance Co.:

Insured Phone:

Group#:

Insurance Co. Address:

State:

Zip:

How much is your deductible?

How much have you used?

Max. annual benefit?

Daily Habits

What type of exercise do you perform on a daily basis?

None

Moderate

Heavy

What do your daily work habits include? (ex: sitting, standing, light labor, heavy labor, computer work)

What vitamins do you currently take?

What kind of other nutritional supplements do you take (if any)?

Do you smoke?

Yes

How much per day?

How much liquor do you consume on a weekly basis?

How much coffee or caffeinated beverages do you consume on daily basis?

Certification & Assignment

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child ever have a change in health.

I certify that I, and or my dependent(s) have insurance coverage with _________________________name of insurance company and assign directly to Dr. ______________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Gaudian or Personal Representative