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Patient Information

Patient Name*
Preferred Name/Nickname*
Date of Birth*
Address*
Emergency Contact Name*

Health History

Are you currently or have you previously had any of the following conditions:*
Check all that apply.
I voluntarily consent to receive medical and health care service to include diagnostic procedures, examination, and treatment. I understand that The Chiropractic Wellness Center of Hudson is required to follow specific privacy regulations. A copy of the Notice of Privacy Practices is available to me at any time by asking a staff member. I authorize The Chiropractic Wellness Center of Hudson to release any medical information needed to determine benefits payable by my insurance policy. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges.
I certify that I have read this form and understand its contents.*
By typing your name, you are signing this authorization form.