Consultation Admittance Information

Please Print

First Name                                                    M.I.                 Last                                                                                       


Nickname                                                     Street Address                                                                                            


City, State                                                                  Zip                  Social Security #                                                    


Female     Male     Marital Status   S   M   W D/S    Spouse Name                                                                          


Birth date                                                                     Home phone                                                                                


Home E-mail                                                                Work/Alternate phone & extension                                         


Fax #                                                                             Beeper /Beeper PIN                                                                      


Cell phone                                                                  Work/Alternate E-mail                                                               


Emergency Contact Person                                                              Phone                                                                    

Claim Information

My condition is due to:    Auto Accident     Personal Injury     Work Injury     Sport Injury     other


Type of Claim:     Cash     Group Insurance     Medicare     Auto Claim     Workers Compensation


I will be paying by     Cash    Personal Check    Visa/ MasterCard (credit)     Visa/MasterCard (debit)

Insurance Information

Relationship to Insured     Self     Spouse    Child     Other                                                                                 


Insureds Name                                                                   Insureds SS#                                                                      


Insureds Birth Date                                                            Insurer                                                                                 


Address                                                           City                                                   State               Zip                            


Policy #                                              Group #                                               Insurer Phone                                          


A.      I hereby authorize release of any health history information necessary to process this claim and request payment of insurance benefits to Crum Chiropractic in consideration of that office accepting the assignment of such benefits.

B.      I authorize payment of any medical benefit from third-parties for benefits submitted for my claim be paid directly to Crum Chiropractic. I authorize the direct payment to Crum Chiropractic any sum I now or hereafter owe this office by my attorney, out of the proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or Crum Chiropractic based upon the charges submitted for goods or services rendered.

C.      I understand and agree that health and accident policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Crum Chiropractic will prepare any necessary reports and forms to assist me in making collection from the insurer and that any amount authorized to be paid directly to Crum Chiropractic will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for products or professional services rendered will be immediately due and payable.


Patients Signature                                                                                       Date                                                              


Guardians Signature                                                                                  Date                                                              

Crum Chiropractic, 16 Woodlake Drive, Holland, PA 18966