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Appointment Booking
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8AM - 6.30 PM only

Person Responsible for Bill (Under 18)

Emergency Contacts

Health Plan Information

Does your insurance require a referral ? (If Yes, you must bring a copy with you to your appointment)

Present illnesses and Questionnaire

Selected Value: 0
0 - 10 ( 0 being the least and 10 being the highest )

Past Medical History

Consent

Please Read the following before signing carefully
Assignment Release and financial Agreement: I authorize treatment of the person named above and agree to pay all fees for such treatment. I hereby authorize my insurance benefits to be paid directly to the provider of service and I am financially responsible for non-covered services. I also authorize the physician to release any information to referring/consulting physicians or other health care providers as your physician deems appropriate to facilitate my care. I agree that I will not withhold or delay payment if my insurance company denies payment on any of my charges. I have also been informed of the $35.00 fee on checks returned. In the event it should become necessary to place for collection an unpaid balance due for services rendered to me or my family, I/we agree to pay interest, collection fees, and should legal action be filed, reasonable attorney fees, filing fees and any other costs.