Application for Care

Application for Care

Patient Information

This is solely for sending a text reminder the day before your appointment; your phone number will not be used for marketing purposes.
Do you have children?
If unemployed, skip this field.

Spouse or Parent Information

In Case of Emergency

Health Insurance Information

In order to make your visit more pleasant, it is helpful for you to provide your health insurance information.
I (we) agree to pay for service rendered to the above mentioned patient as the charge is incurred. I understand and agree that health & accident insurance policies are an arrangement between an insurance carrier and myself that I am personally responsible for payment of any and all services covered or not covered. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered me will immediately due and payable.

By entering my initials below I understand that I accept the above terms.

Additional Information