First Name           Last Name       

   Address                        Town/City      

   State       Zip Code

   Home Phone    Cell Phone

   Occupation Work Phone   Employer

   Address      Zip Code

   Spouse/ Nearest Relative               

   Children   E-mail

   Have you ever been to a chiropractor before? Have you ever been to a chiropractor before? Yes No

   Do you have any symptoms? If so, what are they and how have they affected your life?

   Is this related to an auto accident? Yes No Date of Accident MM/DD/YYYY

   Are you currently under any Medical care? Yes No

   Have you been treated for any health conditions by a Medical Doctor in the last year? Yes No

   If yes, please explain:

   If the Doctor determines that services are necessary, all charges are payable when rendered. What form of payment   will you use?
                     Cash Check Credit Card

   Are you Insured? Yes No If Yes, please send / hand to Receptionist to copy.

  In the event that I make a special arrangement with AHFC, P.C. to bill insurance for me I authorize the release of   any medical or other information necessary to process the claim. I also request payment of government benefits either   to my self or to the party whoaccepts assignment.

   Print Name       Date MM/DD/YYYY
   (This statement is effective for 24 months, unless sooner revoked in writing.)

   Terms of Acceptance

When an individual seeks chiropractic health care and I accept this individual for such care, it is essential for both  to be workingtowards the same objective. Chiropractic has only one goal. The goal is to eliminate Subluxations within the spinal column, which interferes with the expressionof the body's innate wisdom. It is important that you as the patient understand both the objective and the method that will be used to attain our goal. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral Subluxation. My chiropractic method of correction is specific adjustments of the spine and extremities.

Health: A state of optimal physical, mental, and social well being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to expressits maximum health potential. Ancillary treatment: In addition to spinal adjustments I may adjust subluxations in other joints of the body. When necessary Imay also recommend specific exercises and /or therapies such as ice, heat, electrical stimulation or ultrasound. I do not offer to diagnose or treat any disease or condition other than Subluxation. However, if during the course of chiropractic examination we encounter non-chiropractic or unusual findings, I will advise you.

If you desire advice, diagnosis, treatment for thosefindings, I will recommend that you seek the services of a health care provider who specializes in the area. Regardless of what the disease is called, I do not offer to treat it. Nor do I  offer advice regarding treatment prescribed by others. MY ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's innate wisdom. My method is specific adjusting to correct vertebral and joint Subluxations.

I have read and fully understand the above statements.

   Print Name