Schulze Chiropractic Center of San Antonio, TX

SCHULZE CHIROPRACTIC, LLC
DR. RANDALL SCHULZE, DIRECTOR
11924 VANCE JACKSON, SUITE 104, SAN ANTONIO, TX 78230
PHONE: (210) 696-5150 FAX: (212) 696-3556

PATIENT INFORMATION SHEET 

Employment Information

Billing Information

Insurance Information

Release: I hereby authorize the above stated clinic to release any information acquired in the course of my examination which said insurance company may request.

Assignment: I also assign and request payment of medical benefits to the above stated clinic for medical services. I also understand that I am financially responsible for any changes not covered by insurance.