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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

Have you ever:

Family History

Habits

Have you ever suffered from:

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Office Hours

DayMorningAfternoon
Monday9-13-6
Tuesday9 - 11:30Closed
Wednesday9-13-6
Thursday9-13-6
Friday9-1Closed
SaturdayBy Appt.Closed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9-1 9 - 11:30 9-1 9-1 9-1 By Appt. Closed
3-6 Closed 3-6 3-6 Closed Closed Closed

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Testimonial

Dr. McConnell is wonderful! He is very into the fitness world. He completely understands fitness injuries and is so informative. I completely recommended him.

Monica
Nampa, ID

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