You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

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:


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


Have you ever suffered from:

Connect with Us!

New specials for new patients!

THIS ---->https://drbenmatheson.com/new-patient-center/online-forms/new-patient-health-history-form.html

Office Hours

Monday8 am - 1 pm3 pm - 6 pm
Tuesday3 pm - 6 pm
Wednesday8 am - 1 pm3 pm - 6 pm
ThursdayBy AppointmentOnly
Friday8 am - 1 pm3 pm - 6 pm
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8 am - 1 pm 3 pm - 6 pm 8 am - 1 pm By Appointment 8 am - 1 pm Closed Closed
3 pm - 6 pm 3 pm - 6 pm Only 3 pm - 6 pm Closed Closed



Newsletter Sign Up