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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:

Sign up using the form below or call (714) 638-7410 to make an appointment

THIS ---->https://backneckdisc.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday9:00 - 1:003:00 - 7:00
Tuesday9:00 - 1:00On-Call
Wednesday9:00 - 1:003:00 - 7:00
ThursdayOn Call
Friday9:00 - 1:003:00 - 7:00
Saturday9:00 - 11:00Every Other
SundayOn CallOn Call
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00 - 1:00 9:00 - 1:00 9:00 - 1:00 On Call 9:00 - 1:00 9:00 - 11:00 On Call
3:00 - 7:00 On-Call 3:00 - 7:00 3:00 - 7:00 Every Other On Call

Testimonial

Dr Yun and staff are wonderful. He is helping my husband and I.

Francie M.
Garden Grove, CA

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