New Patient Packet

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*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
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 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*

Please check all conditions that apply.