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New Patient Appointment Phone Script Date _________________________________ Time______________________ “When was the last time you saw the Doctor?” ____________________________ “Is this appointment for you or your entire family?”__________________________“Which one of our patient’s referred you?” Mr./Mrs.___________________ Is a wonderful patient and refers a lot of people because he/she knows the many benefits of chiropractic care.” “This office visit will include a consultation at no charge to you. If the Doctor feels that further examinations are necessary, cost will be discussed with you at that time and payment is expected at the time of the visit. Please expect to spend at least 1 hour – a thorough examination procedure will be done.” “Which day is better for you? M__ Tue__ W__ Thu__ F__ Is morning or afternoon better for you? AM __ PM __ “To lessen your wait in our office, I’ll need to know:” Full Name _____________________________________ Home Phone _____________________ Work Phone___________________ Date of Birth ________________ “Will you be filing on:” Auto _________ Workers Comp. ____________ Cash _________ Personal Injury _____________ Group Ins. _____ Company __________________ Auto Patient’s - Name and Address of Ins. Co. ________________________________ Policy # _____________________ Claim #________________________ Please bring any insurance or accident information you may have. I have put an hour aside for your appointment. If for any reason you are unable to make your appointment at this time. Please call us in advance so that we may reschedule you and schedule another patient at this time. Do you know where we are located? - Texoma Parkway, between the two malls, across the street from the Go-Cart track, mirrored building with time and temperature sign out front. We will see you on (Date) _________________ At (time)_________________________
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| New Patient Appointment Form created by Dr. Rick Wren (Founder of The Society of Chiropractic Masters and Parker Team Teacher) |
