Midlothian Medical & Sports Center
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Midlothian Medical & Sports Center
460 S 14th Street Midlothian, TX 76065, US
972-723-1155midlothianchiropractic@yahoo.com
New Patients Paperwork

Responsible Party

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ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE
AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

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Health History
History of Present illness:
Past Medical History

Have you ever had the following: (circle “yes” or “no”/ leave blank if you are uncertain.

Patient Social History:

Indicate which of the below you have experienced in the last 1-2 months
1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

Eyes/Ears/Nose/Throat/Respiratory

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Muscular/Skeletal
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Neurological
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General
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THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT. FL Statute 456.062
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