** Please fill out this form if your service is funded through your health insurance OR if you are paying out of pocket. **
Your signature below forms a binding agreement between Therapy West, Inc. and the Responsible Party for minor patients (those patients under 18 years old) and for patients who are receiving medical services. Responsible Party is the individual who is financially responsible for payment of medical bills.
All charges for services rendered are due and payable at the time of service.