Patient Information *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 *

First Name

Last Name

Phone Number *

(###)

###

####

Address (if different from patient's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2

First Name

Last Name

Phone Number

(###)

###

####

Address (if different from patient's)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's Primary Care Provider

First Name

Last Name

Phone

(###)

###

####

Payment and Cancelation Policy *

I UNDERSTAND THAT I AM RESPONSIBLE FOR THE PAYMENT OF ALL CO-PAYMENTS AND DEDUCTIBLE AMOUNTS FOR SERVICES I RECEIVE. ALL CO-PAYMENTS ARE DUE AT THE START OF EACH TREATMENT SESSION. I ALSO AGREE TO BE RESPONSIBLE FOR ANY FEES INCURRED AT THIS OFFICE SHOULD MY INSURANCE CARRIER FAIL TO PAY FOR ANY TREATMENT SERVICES THAT I RECEIVE. PLEASE BE ADVISED THAT THERE IS A $75 CHARGE FOR ANY TREATMENT SESSION CANCELLED WITHOUT 48-HOURS NOTICE. I RESERVE YOUR APPOINTMENT TIME FOR YOU ONLY AND THERE ARE MANY PATIENTS THAT WAIT ON A LIST TO BE SEEN. I RESPECTFULLY APPRECIATE YOUR COOPERATION AND CONSIDERATION IN ADHERING TO THIS 48 HOUR POLICY. I acknowledge that by typing my name below, I have read and agree to the policy above.

First Name

Last Name

Date *

MM

DD

YYYY