Registration Form

Billing Information

Individual Responsible for Payment (if other than self):

First NameLast Name

Relationship:

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone:

Please enter a valid phone number.

Home Phone:

Please enter a valid phone number.

Work Phone:

Please enter a valid phone number.

Preferred Method of Contact:

CellHomeWork

Insurance Information -

Insurance:*

Policy ID #:*

Group #:*

Employer:*

Subscriber:*

Phone Number:

Please enter a valid phone number.

Secondary Insurance:

Policy ID:

Group #:

Employer:

Subscriber:

How would you like to receive your billing statements?*

EmailMailText

AGREEMENT (Please read and sign below):

I understand that regardless of my health insurance status, I am ultimately responsible for payment of fees.

I agree to pay for any missed appointments with less than 24 hours’ advance notice.

I authorize the release of any information required to process my insurance claims.

I authorize health insurance payments directly to provider.

Client or Legal Guardian Signature:*

Legal Guardian:

First NameLast Name

Date*

Date

OFFICE USE (DO NOT FILL OUT)

Dx: ________________________________________________________________________________

Fee: ________________________________________________________________________________

Notes: ______________________________________________________________________________