Self-Pay Information Form

Patient Name *

Patient Date of Birth *

Who is financially responsible for the charges?

Self Parent/Guardian Other

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

Yes No

Address

Street Address

Street Address Line 2

City State / 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:

Physical Therapy:

Dancer: Initial Eval $85, Follow-Up Visit $75

Other Clients: Initial Eval $95, Follow-Up Visit $85

Prehab (Strength/Conditioning/Pilates)

Individual Session: $60

The preferred option for self-pay patients is to have a card on file, which receives a $5 discount per visit. If you prefer not to have a card on file, payment is expected at the time of service. Pre-paid packages can also be purchased online, and offer additional discounts. Financial aid and payment plans are available upon request.

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. (This option receives a $5 discount per visit.) I will pay in full at each visit. I will use a pre-paid package. (Please note that until a package is purchased, the full-price will apply.) I have requested a payment plan.

Signature *

Clear