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Chiropractic Confidential PatientHealth RecordToday's Date: / / Patient Number:Personal InformationTitle: ? Mr. ? Ms. ? Mrs. ? Dr. ? Rev. ? Miss ? Prof. ? Other: Last: First: Middle: Birth Date: /
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Start by gathering all necessary information such as personal details, medical history, and insurance information.
02
Begin filling out the patient information section by providing your full name, address, phone number, and date of birth.
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Provide details about your primary complaint or reason for seeking chiropractic care.
04
Fill in any medical history, including previous injuries, surgeries, or medical conditions that may be relevant.
05
Indicate any current medications or supplements you are taking.
06
If applicable, provide information about your insurance coverage and policy number.
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Sign and date the form to confirm accuracy and consent.
08
Submit the completed form to Eugene Family Chiropractic either in person or through their preferred method (mail, fax, email).

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Eugene Family Chiropractic 36 is a form used for reporting chiropractic services provided to patients.
Chiropractors who provide services to patients are required to file Eugene Family Chiropractic 36 form.
The Eugene Family Chiropractic 36 form must be filled out by providing detailed information about the chiropractic services provided to patients.
The purpose of Eugene Family Chiropractic 36 is to accurately report the chiropractic services provided to patients for record-keeping and billing purposes.
Information such as the date of service, type of service provided, patient's information, and any additional notes must be reported on Eugene Family Chiropractic 36.
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