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New Patient Form

Green Sheet

PATIENT INFORMATION

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT

INSURANCE

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with ___(Name of Insurance)___ and assign directly to JERNIGAN CHIROPRACTIC CLINIC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from date signed below.

ACCIDENT INFORMATION

PATIENT CONDITION

Health History

Date of Last:

Place a mark on “Yes” or “No” to indicate if you have had any of the following:

Injuries/Surgeries you have had

Exclusive Offer

New patients receive 15% OFF first visit.

THIS ---->https://jerniganchiro.chiromatrixbase.com/new-patient-center/Green-Sheet.html

Office Hours

DayMorningAfternoon
Monday8:00-12:002:00-5:00
Tuesday8:00-12:002:00-5:00
Wednesday8:00-12:002:00-5:00
Thursday8:00-12:002:00-5:00
Friday8:00-12:002:00-5:00
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00-12:00 8:00-12:00 8:00-12:00 8:00-12:00 8:00-12:00 Closed Closed
2:00-5:00 2:00-5:00 2:00-5:00 2:00-5:00 2:00-5:00 Closed Closed

Reviews

I was in an accident several years ago. It led to chronic neck and low back pain and I had headaches every day. Dr. Jernigan helped me get out of pain and stay out of pain

M. Smith
Gulfport, MS

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