New Patient Form – Ocean Reef – South Florida Chiropractors

Offices of Dr. Howard Furshman

Questions? Please contact us: (305) 668-9545

Name

First

Last

Date of Birth

Address

Please Who (For

Phone Number

Please confirm your preferred office location

Ocean Reef

Who Referred You To Us?

Chief Complaint

Release of Assignment

I authorize release of any information necessary to process my insurance claims only. I also assign and request direct payment to my physician if I utilize Medicare or personal injury protection insurance.

Non Pregnancy (For Women Only)

I hereby notify all concerned that I neither suspect nor know positively at this time that I may be pregnant. I release this clinic from any and all damages arising from any and all procedure of diagnostic x-ray or treatment with reference to the possibility of pregnancy.

Consultation and Consent (Under 18)

I am the Legal Guardian and hereby authorize Furshman & Davis Family chirorpactic to administer care, deemed necessary.

Schedule Your Appointment

After completing this form, I understand that I must call (305) 668-9545 to schedule my appointment.

Date signed