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

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Family History

Habits

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Contact

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Magnolia Chiropractic Center
17278 Airline Hwy Suite C
Prairieville, LA 70769-3451
Get Directions
  • Phone: 225-313-4605
  • Fax: 225-313-4607
  • Email Us

Business Hours

DayMorningAfternoon
Monday7:00 - 12:002:00 - 7:00
Tuesday7:00 - 12:002:00 - 7:00
Wednesday7:00 -12:002:00 - 7:00
Thursday7:00 - 12:002:00 - 7:00
Friday7:00 - 12:00Closed
SaturdayClosedClosed
SundayClosedClosed

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