Contact South Main Chiropractic Clinic Today!

Mon, Wed, Thu: 9:00 AM - 1:00 PM and 2:30 PM - 6:00 PM

Tue & Fri: 9:00 AM - 1:00 PM

Sat & Sun: Closed

**Therapy Only on Friday's**

Address:

South Main Chiropractic Clinic

1920 S Main St High Point, NC 27260

Phone: (336) 885-5200

Email: smcchpt@northstate.net

Patient Intake Form

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PATIENT INFO

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IN CASE OF EMERGENCY

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REASON FOR YOUR VISIT

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PERSON RESPONSIBLE FOR THIS ACCOUNT

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INSURANCE INFORMATION

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WHO REFERRED YOU TO OUR OFFICE?

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CONSENT TO TREATMENT

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I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examinations and treatment.

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FINANCIAL RESPONSBILITY AND ASSIGNMENT OF BENEFITS

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I agree to pay all charges for medical and health care services not covered by my insurance company.

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PATIENT OR OTHER LEGALLY AUTHORIZED PERSON

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