Registration 2

Patient Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone Number*

Email*

example@example.com

Gender*

MaleFemale

Upload a picture of yourself or take one by clicking the button below*

Take Photo*

Main Concern / Reason For Appt.*

Who referred you to us?*

Emergency Contact*

First NameLast Name

Emergency Contact - Relationship to the patient?*

Emergency Contact - Phone Number*

CONSENT TO TREATMENT: I voluntarily consent to receive medical and health care services that may include diagnostic procedures examinations and treatment.*

YesNo

FINANCIAL RESPONSIBILITY: I agree to pay all charges for medical and health care services at Vitality Health & Wellness and understand that payment is due prior to or at the time that services are rendered. I understand that the clinic is not “in-network” with any insurance companies and that the office operates as a “fee-for-service” office and that all services must be paid for at the time of the visit. I understand that I will be paying for “contact” with the doctor whether by email, phone or in-person; irregardless of whether my insurance offers reimbursement for this type of contact (charge for “non-local” contact will be at the clinic's discretion and will be charged at prevailing rates; however, in most cases this will not apply for urgent phone contact that lasts less than five minutes). I agree to allow Vitality Health & Wellness to charge my credit card for any outstanding balances that may occur from time to time*

YesNo

CANCELLATION POLICY: I understand that the office has a strictly enforced 24-hour cancellation policy and does not include weekends or holidays (i.e. an appointment scheduled for Monday morning at 10 am must be canceled by 10 am on Friday morning in order to avoid a cancellation charge). Cancellation fees will be based upon the amount of time that is scheduled for the office visit. The office will attempt to contact you as a courtesy prior to your scheduled appointment time as a reminder. Please be aware that when you reschedule your appointment, there will be a charge for that new appointment and the missed / cancellation within 24 hours fee does not get applied to the next appointment*

YesNo

Signature*