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CHIROsport&Spine 421E. Mainstream Endicott,NY13760 PH:(607)3217674 Fax:(607)2396772PATIENT INTAKE FORM Name: Date of Birth: Nickname: Age: Gender: (circle one)malefemaleAddress: City: State: Zip Code:

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What is chirosportampspine?

Chirosportampspine is a form used for reporting chiropractic sports and spine services.

Who is required to file chirosportampspine?

Chiropractors who provide sports and spine services are required to file chirosportampspine.

How to fill out chirosportampspine?

Chirosportampspine can be filled out by providing detailed information about the chiropractic sports and spine services provided.

What is the purpose of chirosportampspine?

The purpose of chirosportampspine is to track and report chiropractic sports and spine services for regulatory and healthcare purposes.

What information must be reported on chirosportampspine?

Information such as date of service, type of service provided, patient information, and billing codes must be reported on chirosportampspine.

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