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(203) 750-0010

The Chiropractic Office of Dr. Kenneth Passero

228 West Rocks Rd, Norwalk, CT 06851

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









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______________________________________




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_________________________

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