New Patient FormStep 1 of 5 - Contact Information20%Want to download a printable version of the form? Click hereYour Contact InformationName(Required) First Last Middle Initial(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Responsible PartyComplete if patient is a childBest Contact Number(Required)Type of Phone(Required) Work Cell Home2nd Contact NumberType of Phone Work Cell HomeDate of Birth(Required) MM slash DD slash YYYY Gender(Required)Ethnicity(Required) Hispanic Non-hispanicRace(Required) Caucasian African American Asian OtherOtherPreferred Langauge(Required) English Spanish OtherOtherEmail Material Status(Required) Single Maried Divorced WidowedNumber of ChildrenEmployeerOccupationAre you a student?(Required) Yes NoHow did you hear about us?(Required)Insurance CompanyName of Person Insured First Last Date of Birth for Insured Person MM slash DD slash YYYY Relationship to Insured PersonMajor ComplaintConditionsPlease check any of the following that give you difficulty or you have recently had: Acid Reflux Allergies Anemia Asthma Bed Wetting Bowel Issues Celiac Disease Chest Pain Cold Hand/Fingers Cold Feet Constipation Crohn's Disease Depression Dizziness/Vertigo Ear Problems Eye Problems Fainting Fatigue Hay Fever Headaches Heartburn Heart Attack Hermia High Blood Pressure High Cholesterol Hip Pain Infertility Irritability Irritable Bowel Syndrome Kidney Trouble Loss of Smell Loss of Taste Low Blood Pressure Menstrual Problems M.S. Nervousness Number arms/hands Number legs/feet Osteopenia Painful Joints Pins/Needles - arm/hand Pins/Needles - leg/foot Prostate Trouble Rheumatoid Arthritis Shortness of Breath Sinus Trouble Skin/Hair/Nail Problems Sleeping Problems Spinal Curvature/Scoliosis Stroke Swollen Extremities Thyroid Trouble Ulcers Ulcerative Colitis Urinary Problems Weight Change (unplanned)ConditionsHave you had chiropractic care before? If so, when:Status of your symbols: Improving About the same Comes and Goes Getting WorseHave you had any major falls, accidents (including auto), or injuries?List any surgeries you've had:List any prescription medicine you're takingList any supplements or over the counter meds you're talkingDo you have any allergies to any medications? If so, what?Do you currently smoke?(Required) Yes NoHave you ever smoked?(Required) Yes NoWhat type and how much?What is your exercise level?(Required) None Light Moderate StenuousWhat is your stress level?(Required) Mild Moderate ExtremePhysical Activities at work(Required) Sitting 50% or more Repetitive Motions Light Labor Manual Labor Heavy LaborTo the best of your knowledge, are you currently suspected or confirmed pregnant? Yes NoFamily HistoryPlease List: FATHER, MOTHER, SIBLING, PATERNAL GRANDFATHER, PATERNAL GRANDMOTHER, MATERNAL GRANDFATHER , MATERNAL GRANDMOTHER, DECEASEDAneurysmArthritisBack problemsCancerDiabetesHeadaches/MigrainesHeart DiseaseHigh Blood PressureOsteoporosisScoliosisStrokeUlcersConsentsConsent(Required) I agreeI UNDERSTAND THAT MY RECORDS ARE KEPT CONFIDENTIAL AND I CERTIFY THAT THE INFORMATION I HAVE PROVIDED HERE IS TRUE TO THE BEST OF MY KNOWLEDGEConsent(Required) I agree to the Assignment of Benefits PolicyI understand and agree that I am ultimately responsible for payment. I hereby authorize and direct my insurance company and/or attorney to pay by check or direct deposit to Daude Family Chiropractic, PC, 55185 Shelby Rd, Shelby Twp, MI 48316. Further, I agree to pay the difference, if any, between the total amount of charges and the amount paid by my insurance and/or attorney. I also agree to pay the full amount of charges should they not be covered by my policy or if my insurance company or attorney refuse payment. THIS IS A DRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.Consent(Required) I agree to the Office Financial Policy• All patients should provide accurate and complete personal and insurance information prior to being seen by the doctor. • All applicable co-pays, personal balances, both current and prior, are due at time of service. • We accept cash, check, or credit cards. • We participate in most insurance plans, however we require that the guarantor, the person who is financially responsible, is personally liable for all balance not covered by insurance. It is your responsibility to understand and comply with any Pre-determination of benefits or referral requirements. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under the Medicare Program or by other medical insurance companies.This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.EmailThis field is for validation purposes and should be left unchanged.