Billing Form

BILLING
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Therapist Selected
Provider: *
Coverage Information:

Policy #Member ID
Coverage Limit:
Name of Insurance Cardholder (if different from patient information):

First NameLast Name
ParentChildFull-Time StudentSpouse
POSTAL CODE*
I consent to have Allegro Counselling Inc. process my credit card for the psychological services rendered upon completion of the service and / or process the direct billing, if available. I understand that my information will be saved to file for future transactions of my account.
Date*

MonthDayYear
Date
Signature*

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BILLING