Chiropractic Health Service Dr. Clay Reynolds III D.C
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Insurance

If you are a new patient and would like to expedite your paperwork, just fill out the information below we will process your information.

Patient Information

Patient Name:

Date:

Email:

Address:

City:   Zip:

Phone: Home

Office: Cell:

Payment Option: Cash Check Insurance

Insured Name:

Referred by:   Best Time: Morning Afternoon:

Auto Accident?
Date of accident:   

Place:

Time: Claim No.
Is this a no fault State? Yes No  
Has this been reported to Insurance Company? Yes No  
Police called? Yes No  
Have you filled out a benefit request application? Yes No  
Police Report? Yes No  
Name of Insurance Company:
Agent: 
   

 

 

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