New Patient Appointment

I do hereby consent to any medical care which is deemed advisable or necessary by my physician and grant authority to Arthros LLC
DBA Ur-Care Health Centers, to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in
the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance and any
other health plan, are assigned to Arthros, LLC DBA Ur-Care Health Centers. The signature below confirms all the information provided herein
is true and accurate. Photocopy of this consent is to be considered as valid as the original.

I hereby acknowledge that I have received a copy of Ur Care Health Centers Notice of Privacy Practices as required by federal law.

I hereby acknowledge that I have received a copy of Ur Care Health Centers Notice of Privacy Practices as required by federal law.

Dear Patient, UR Care Center has instituted an Appointment Cancellation Policy.
A cancellation made with less than a 24 hour notice significantly limits our ability to make the appointment available for another patient in need.
To remain consistent with our mission, we have instituted the following policy:

1. Please provide our office a 24-hour notice in the event that you need to reschedule your appointment. This will allow us the opportunity to provide care to another patient.

2. A “No-Show”, “No-Call” or missed appointment, without proper 24-hour notification, may be assessed a $50 fee.

3. This fee is not billable to your insurance.

4. As a courtesy, we make reminder calls, for appointments, one to two days in advance.
Please sign and date below your acknowledgement.

I have read and understand the Appointment Cancellation Policy and I acknowledge its terms. I also understand and agree that such terms may be amended from time-to-time by the clinic.