Patient Registration Logo

  • New Patient Registration

  • New Patient Instructions

    If you are interested in making an appointment, please be sure you have reviewed all information on our website www.carolinacenter.com under “NEW PATIENTS”, then “HOW TO BECOME A PATIENT” before completing these forms. All forms must be completed BEFORE your initial office visit can be scheduled.
  •  - -

  • Please provide a copy or photo of your driver's license (front and back) or other official identification as required by the US Patriot act. Failure to provide these files will delay scheduling.

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Financial Obligation Statement

    The services you are electing to receive imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full of any and all charges incurred. As a courtesy, we will verify any insurance coverage and bill your insurance carrier on your behalf with the exception of Medicare, Medicaid, and Blue Cross Blue Shield; however, you are ultimately responsible for the payment of your bill. Payment for all office visits, procedures and other services is expected at the time the service is provided. Payment is also due immediately upon receipt of any bill presented to cover any deductible or coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim you will be obligated to pay your account balance in full. I authorize my insurer to pay any benefits directly to Carolina Center for Integrative Medicine. I also agree to pay the Carolina Center the full and entire amount of all bills incurred by me within 30 days of treatment or upon receipt of any amount due after payment has been made by my insurance carrier. I understand that I will be assessed interest of 15% on any unpaid balance after 30 days and this interest will continue to accrue until payment is made in full. I have read the above policy regarding my financial responsibility to the Carolina Center for providing services to me. I certify that the information provided is, to the best of my knowledge, true and accurate.
  • Clear
  •  - -
  • Clear
  •  - -

  • New Patient Cancellation Policy

    The non-refundable application fee and deposit of $250 is due at the time your New Patient appointent is scheduled.  The balance is owed prior to your initial visit.  

    This balance is fully refundable up to two weeks prior to the scheduled office visit. No refunds will be made if a cancellation request is received after this time period; however, patients will be allowed one opportunity to reschedule with a $150 cancellation fee. If this rescheduled appointment is then cancelled again or the patient is a no-show, the patient will not be allowed to reschedule any appointments and will forfeit all payments.

    Under these circumstances, you must reapply to be a new patient after a 3-month waiting period and submit a new Patient Registration Form along with another $250 deposit. No credit will be given for any previous payments made. There will be no waivers of these fees for New Patients.

    Please sign and date that you agree to this policy.

  • Clear
  •  - -

  • No Perfume-Scented Toiletries Policy

    For everyone's sake, please be aware of our No Perfume-Scented Toiletries policy and refrain from wearing any perfume or scented toiletries while at the clinic. Non-compliance may result in you being asked to leave and being assessed a cancellation fee.

    I have read all the information on the Carolina Center website under “New Patients” and “How to Become a Patient” and understand these procedures.

    I have read the “Orientation Handbook” and understand this information. I am requesting to become a patient of the Carolina Center and understand that it is highly recommended that I attend the “Introduction to the Carolina Center” Group Orientation prior to my visit although this is not required. 

    Please sign and date that you acknowledge this policy.

  • Clear
  •  - -

  • New Patient Orientation - "Intro to The Carolina Center"

    We greatly appreciate your interest in becoming a patient at the Carolina Center. In contrast with conventional medicine, integrative medicine involves an entirely different way of thinking about health and the body. The processes and procedures we follow are not always familiar to people. We need to obtain a great deal of information from you in order to provide the best care. There is also much you will need to learn from us. While optional, it is strongly recommended that all new patients attend one of our regularly scheduled “Introduction to the Carolina Center” group orientations. During this time you will meet Dr. Pittman and learn the basics of a cellular-based integrative approach and have your questions answered. If you were unable to attend the New Patient Orientation prior to your initial office visit we strongly encourage you to attend a session prior to your first follow-up office visit.
  •  - -
  • Should be Empty: