If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Call Us Today

(203) 750-0010
m

The Chiropractic Office of Dr. Kenneth Passero

228 West Rocks Rd, Norwalk, CT 06851

ph: (203) 750-0010 fax: (203) 750-0015

www.passerochiropractic.com

 

 

 

Name_______________________________________Date____________________

 

Address______________________________________________________City_____________________

 

State_______________Zip Code________________Social Security #__________/_________/_________

 

Date of Birth_____________/_____________/______________Age_______________________________

 

Home Phone:(______)_____________________Work Phone:(______)____________________________

 

Cell Phone:(______)_______________________E-Mail Address:________________________________

 

Marital Status: S  M  D  W   # of children, ages and sex______________________________________

 

Occupation:____________________________Employer:_______________________________________

 

Name of Emergency Contact:_____________________________Phone #:_________________________

 

Referred to this office by:_________________________________________________________________

 

Please allow our office to make a copy of your insurance card

 

Is your current condition the result of an auto or work accident? Yes___ No ___  Auto ___ Work ___

 

Medical Release/Assignment of Benefits

I authorize the Chiropractic Office of Dr.Kenneth Passero to release any Protected Health Information necessary to process my claim for health care benefits.  I agree to assign the benefits of my insurance carrier to Dr. Passero.  I understand that I am fully responsible for any unpaid or unassigned portion of charges incurred at this office.  Regardless of insurance status, charges for services rendered are ultimately the patient's responsibility.

Permission to communicate confidential health information

I authorize the Chiropractic Office of Dr. Kenneth Passero to communicate confidential health information to me via the following confidential formats: ___e-mail listed above, ___voicemail/answering machine at the following number:_________________________________:  ____ Only speak with me directly!!

 

 

Patient's Signature________________________________________Date_________________________

Featured Services

Services
We strive to provide complete care for our patients. Learn more about all the services we provide.
Make An Appointment
We will do our best to accommodate your busy schedule. Schedule an appointment today!
Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.