Authorization for Minor Mobile Check-In

Authorization for Minor Mobile Check-In
Holt Location: 2380 Cedar Street Suite 203 Holt MI 48842

Frandor Location: 3315 E Michigan Ave Suite 6 Lansing MI 48912

Grand Ledge Location: 615 S Clinton Suite Grand Ledge MI 48837

Howell Location: 751 S Latson Road Suite C Howell MI 48843

P: 517-709-4677 F: 517-798-5667
I, the undersigned, authorize Premier Rehabilitation to send text messages for mobile check-in purpose to the following phone number:
Phone Number
Please enter a valid phone number.
I understand that any required payment is expected at the time of check in via one of the following ways: credit card saved on file and authorized during the mobile check-in process, or another method of payment (credit card, cash, or check) must be presented by the patient at the time of check in.

I certify and acknowledge that I have read and fully understand the above statement and have provided any required information.
Please print the patient's name*
Please print your name*
Please sign your name*

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Please specify your relation to the patient*
Date*

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Date
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