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Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

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Family History

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Office Hours

DayMorningAfternoon
Monday9-13 - 6
TuesdayClosed3 - 6
Wednesday9 - 13 - 6
ThursdayClosedClosed
Friday9 - 1closed
SaturdayBy AppointmentClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9-1 Closed 9 - 1 Closed 9 - 1 By Appointment Closed
3 - 6 3 - 6 3 - 6 Closed closed Closed Closed

Testimonial

Dr. Patrice Thompson is hands down the best! With my husband having migraines she educated him on the benefits of chiropractic care, and was able to ease stress and pain stemming from his migraines. My husband and I can't wait to be adjusted again!! Thank you so much!

S. Dukes
East Point, GA

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