New Patient Packet

Name of Patient*

First NameLast Name

If patient is a minor, please type responsible parties name here.

Relationship to Patient (If applicable)

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Marital Status*

SingleMarriedOther

Name of Spouse (If applicable)

Place of Employment*

Job Description*

Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.

Dr. Kevin's Wellness Clinic Financial Office Policies

1) All patients are on a cash basis.

2) This office accepts MC, VISA, DISCOVER, AMEX, Care Credit, Proceed Finance, Personal Checks, & Cash.

3) If this office gives you any professional or accounting discounts for treatment, and you decide to drop out of care, then our standard fees will apply when a refund is issued.

4) If you have any questions concerning this or any other matter, please speak with the receptionist prior to seeing the doctor.

5) If you stop care and have a financial agreement signed with our office, you will be responsible for any/all charges that you have incurred at our office.

6) Your initial $350.00 payment is NON-REFUNDABLE.

Thank you for your cooperation in this matter.

I have read and fully understand the financial office policy and agree to abide by these terms.

Signature*

New Patient Packet

Please check all conditions that apply.