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In order to provide you the best possible wellness care, please complete this form

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

Have you ever:

Family History

Habits

Have you ever suffered from:

We will treat you on your first visit, provide high quality care and service that is focused on getting
you back to doing what you love.

 

Office Hours

Weddington Location  
1928 Monroe-Weddington Rd,
Weddington NC 28104
 

Monday 8am-12pm & 1pm to 7pm
Wednesday 8am-12pm & 1pm-7pm
Thursday 3pm-7pm
Friday 8am-1pm

Indian Land Location  
5090 Ridgeline Ln,
Indian Land SC 29707. 

Tuesday 8am-12pm & 3:30pm - 7:30pm
Thursday 8am - 12pm