Male   Female

First Name:                          Last Name:

Middle Name:                        What you prefer to be called: 

Referred by: Patient/Friend Doctor Website/Internet Yellow pages Sign Advertising Insurance Company Other If other:

Patient/Friend/Doctor:

   Name:

Yellow pages:

   Town: Rock Hill Fort Mill York Lake Wylie Chester Lancaster Section: Chiropractic Medical Physical Therapy Psychology Pain Management  

Advertising: 

   Type: Television Radio Newspaper  

   Newspaper: The Herald The Fort Mill Times The Lake Wylie Magazine The Yorkville Enquirer  

Insurance Company:      

   Type:   Representative Booklet Other  

       If other:

   Agency: Aetna Atlantic Health Plans Blue Cross Blue Shield Capp Care Cigna Companion CorVel Care Doctor's Health Plan First Health Focus Healthcare Great West Guardian Healthcare Savings HealthStar HealthSource Jefferson-Pilot John Alden Kanawha Mamsi Maxicare MedCost Nationwide One Health Plan Physicians Care Network Premier Health Systems Principal PHCS Prundential Tenet Wellness Plan Well Path Other  

       If other:

Birthdate:     January Feburary March April May June July August September October November Decmber 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000     Age:

Status:  

Minor Single Married Divorced Separated Widowed None of Your Business

Street Address:                      

PO Box/ Suite#:                       

City:                                    

Rock Hill Fort Mill Fort Lawn York Lake Wylie Lancaster Chester Indian Land Gastonia Great Falls Richburg Blackstock Charlotte Clover Hickory Grove Sharon Kings Mountain Winnsboro Waxhaw Other If other:

State:                 

NC SC Other If other:

Zip:                                        

Phone Numbers:   

   Home:        

   Work:         

   Pager/Cell:  

   Other:         

Occupation:

Employer:

E-Mail:

Emergency Contact:                

             Name                                Relation

          Home Phone                      Work Phone

Reason for Consult: 

Pain Illness Wellness Other    If other:

Comments: