1. I {printName} give permission for Exquisite Wellness to give me medical treatment.

2. I allow Exquisite Wellness to file for insurance benefits to pay for the care I receive.

Exquisite Wellness will have to send my medical record information to my insurance company.
•I must pay my share of the costs.

•I must pay for the cost of these services if my insurance does not pay or I have no insurance.

I understand:

•I have the right to refuse any procedure or treatment.
•I have the right to discuss all medical treatments with my clinician.