New Patient Forms

At South Bay Wellness Center & Chiropractic in San Jose, we want to make your visit to our office a convenient and efficient experience without the trouble of having to wait to fill out the required paperwork in the office. Now you can do it from the comfort of your own home.


Welcome to Ebadat Chiropractic, Inc. 

South Bay Wellness Center 

Patient Information

Thank you for choosing Ebadat Chiropractic, Inc. for your chiropractic needs. If you have any questions or concerns, please do not hesitate to ask for assistance. We are happy to help! 

Do you prefer to receive calls at:
Marital Status:

Responsible Party 

Insurance Information 

Symptoms 

Which activities are difficult to perform?
Type of Pain:
Rate the severity of your pain (1 = mild pain or discomfort, 10 = severe pain):
Is the pain:
What treatment have you received for this condition?

Health History 

Check only those that are applicable:

WOMEN: 

Daily Habits

What type of exercise do you perform daily?
Do you smoke?

Certification and Assignment 

To the best of my knowledge, the above information is complete and accurate. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. 

I certify that I, and/or my dependent(s), have insurance coverage with, and assign directly, to Dr. Jay Ebadat all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. 

Dr. Jay Ebadat may use my health care information and may disclose such information to the above insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the signed date. 

Thank you for taking the time to fill out this form.