New Customer Registration Form
Customer Details:
Full Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Other
Please Specify
*
Emergency contact
First Name
Last Name
Emergency contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance carrier
*
Upload insurance card
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Consent to Treat
I voluntarily consent to evaluation and treatment by BradRich Healthcare, LLC. I understand that I have the right to ask questions and can refuse any service or treatment at any time.I authorize BradRich Healthcare to provide care, recommend treatment plans, and make appropriate referrals as needed. This consent remains in effect unless revoked in writing.
Signature
*
*
I have read and consent to treatment.
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HIPAA Acknowledgment
I acknowledge that I have been offered access to BradRich Healthcare’s HIPAA Notice of Privacy Practices. I understand that my health information is protected and will be used only as outlined by law and clinic policy.
Signature
*
*
I acknowledge receipt of the HIPAA privacy notice.
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Financial Responsibility Agreement
I understand that I am responsible for all charges incurred at Brad-Rich Healthcare, including those not covered by my insurance.
Signature
*
*
I agree to the terms of financial responsibility.
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