FIRST TIME PATIENTS

FIRST TIME PATIENTS

Please fill out this form completely to register for your first visit

AFTER COMPLETION, WE WILL REACH OUT TO SCHEDULE YOUR EXAM.

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About Your Problem

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Estimate if needed

Health History

Authorization and Release

I authorize my insurance benefits to be paid to Brian Cox PT & Chiro (if applicable).

I consent to the release of my diagnostic reports to Brian Cox PT & Chiro.

I will pay for all fees not covered by my insurance.

I agree to email correspondence with Brian Cox PT & Chiro.

I had opportunity to review the notice of privacy practices listed below this form.

I confirm that the information above is accurate and complete.

Confirmation and Signature

The "E-signature" below stands in place of a physical legal signature confirming that I agree to the terms listed under Authorization and Release.
First and Last legal name
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Date of E-Signature
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