WARNING

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

Close [x]

Follow Us

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

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 ____________________