Lexington Chiropractor | Lexington chiropractic care | SC | New Patient Forms

Lexington Spinal Care

524 Columbia Avenue,

Lexington SC 29072 

803-356-1350

Chiropractic at its best!

 

WEBSITE SPECIAL 

$47  Comprehensive Chiropractic Examination, including 2 X-rays, if needed.

CALL NOW to reserve your appointment time.

803-356-1350

Business Hours
Monday:7:30--12:00 2:30-6:00
Tuesday:2:30-6:00
Wednesday:7:30-12:00 2:30-6:00
Thursday:7:30-12:00 2:30-6:00

New Patient Forms

 

Patient Information

Full Name______________________________________________________________________________________

Date of Birth __________/___________/________ Age_______ Male            Female

Are you Pregnant?       Yes       No      If yes, when is your expected due date______________________________

Address_______________________________________________________________________________________

City______________________________________________ State____________ Zip code___________________

Home Phone#(_______)_____________________ Alternate Phone#(_______)__________________________

Email Address(will not be sold)____________________________________________________________________

Employer’s Name__________________________________ Occupation___________________________________

Work Address______________________________________ City________________________________________

State_____________ Zip Code________________ Work Phone#(______)___________________ EXT._________

Marital Status:                  Single                  Married                 Widowed

Emergency Contact _____________________________________ Phone #(_________)____________________

-----------------------------------------------------Claim Information-----------------------------------------------------------------------------

Is your condition due to:  Auto Accident                 Personal Injury                 Work Injury                      Other

Type of Claim:     Cash        Group Health Insurance      Personal Injury          Workers Comp                    Medicare

I will be paying today by:          Cash                    Check                       Credit Card                       Other

----------------------------------------------------Insurance Information -------------------------------------------------------------------------

Primary Insurance: Relationship to insured?      Self              Spouse            Child                Other

Insured ‘s Employer___________________________________________________________ or Same as above

Insured’s SSN _________-________-_______ and Date of Birth _____/_____/_____

Secondary Insurance: Relationship to insured ?       Self       Spouse       Child          Other

Insured ‘s Employer_______________________________________ or Same as above

Insured’s SSN _____-____-_____ and Date of Birth _____/_____/_____

I hereby declare that all the above information is correct.

Patient/Guardian Signature_____________________________________________Date_____________________

 
 
Lexington Chiropractor | New Patient Forms. Dr. Edward Carpenter is a Lexington Chiropractor.