Hudson : 330-342-0755 | Brimfield : 330-968-6256

General Information

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Patient Information

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If unemployed, skip this field.

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Additional Information

Insurance Information

In order to make your visit more pleasant, it is helpful for you to provide your 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.

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