Weis Chiropractic & Physical Therapy Center 10671 McSwain Drive
Cincinnati, OH  45241
Voice: 513.563.0414  FAX: 513.563.9540

Patient Information Form

Please Print or Type

Date ______________

PATIENT INFORMATION

Last Name: _________________________________________________________________

First: ______________________________________________________________________

Middle Name (Initial): _________________________________________________________

SSAN: _______ - _____ - _________

By what name would you like to addressed: ________________________________________

Address: ____________________________________________________________________

City: _______________________________________________________ State: ______

Zip: ___________

Phone: (______) _________________

# of Children (if applicable): _______

Date of Birth: ________________

Age ____ Male ____ Female ___ Married ___ Single ___ Divorced ___ Widowed ___

E-Mail Address: ______________________________________

Occupation: _________________________________________

Employer Name: ______________________________________

Address: _____________________________________________________________________

City: ________________________________________________________________________

State: ______ Zip ___________

Phone: (_____) _____________

PATIENT SPOUSE (OR IF MINOR, PARENT) INFORMATION

Name: ________________________________________

Date of Birth: _________

Occupation: __________________________________________

Spouse Employer: ______________________

Employer's Address:___________________________________________________________

City: ________________________________________ State: ____ Zip: __________

Phone: (______) _________________

Primary Care Physician: _______________________________________________________

Phone: (______) _________________

PATIENT REASON FOR VISIT

Chief Complaint (please describe below) :

___________________________________________________________________

PAYMENT DETAILS

PAYMENT / CO-PAY IS EXPECTED AT TIME OF VISIT

Individual Responsible for Payment:______________________________________________

Are you insured? Yes ___ No ___ 

Insurance Company Name ______________________________________________

Are you eligible for Medicare? Yes ___ No ___  Is Medicare Primary? Yes ___ No ___

Name of Insured: ___________________________________________

Date of Birth of Insured: __________________

Address of Insured: ____________________________________________________

City ______________ State: ____ Zip: ________

_____________________________________________
Patient Signature