Lisa Pisani Registration

Lisa R. Pisani, M.A., LCMHC
112 Lake Street, Burlington, VT 05401
Tel. (802) 865-3450
Fax (802) 859-3309
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Gender:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Occupation:
Employer:
Physician:

First NameLast Name
Date of Last Exam:

MonthDayYear
Date
Emergency Contact Information
Emergency Contact:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
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 Signature:
Date:
Legal Guardian:

First NameLast Name
Legal Guardian Signature:
Date:

MonthDayYear
Date
OFFICE USE (DO NOT FILL OUT)

Dx: ________________________________________________________________

Fee: ________________________________________________________________

Notes: ______________________________________________________________
Should be Empty: