Self-Pay Information Form

Self-Pay Information Form
Patient Name*
Patient Date of Birth*
Who is financially responsible for the charges?

SelfParent/GuardianOther
Is the address of the responsible party the same as the patient's address?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Person Responsible for Payment*
Phone Number of Person Responsible for Payment*
Please enter a valid phone number.
Email of Person Responsible for Payment*
Payment Policies

Our self-pay rates are as follows:

Dancer Clinical Services: Initial Eval $90/Follow-Up Visit $80

Physical Therapy

Mental Health Counseling

Nutrition Counseling

Elite Performance Prep: $65

Cross Training (strength/conditioning, Pilates, Gyro)

Mental Performance Coaching

Massage

Other Client Clinical Services: Initial Eval $100, Follow-Up Visit $90

Physical Therapy

Mental Health Counseling

Nutrition Counseling
I have read the above and my payment choice is indicated below.*

I will have a card on file and authorize Carolina Dancer Wellness to charge my card at the time of service. (A card-on-file authorization agreement will be emailed to you and must be completed before the end of the first visit.)I will pay in full at each visit.I prefer to receive monthly statements. I understand that this option has a $5 service fee, payment is due within 30 days of receipt, and that a late fee of 10% is applied for payments received after 30 days.I have requested a payment plan.
Signature*

Clear
Should be Empty: