New Patient Registration and Financial Policy
Thank you for choosing Life Wellness Centre to assist you in achieving and maintaining your health and well-being. We are committed to your successful treatment. We feel that everyone benefits when there is a definite and clear financial agreement prior to treatment. In an effort to maintain the highest level of professional care possible, we have established the following as our financial policy, which we require you to read and sign before receiving treatment: Full payment is due at time of service. We accept cash, checks, and all major credit cards.
We do not accept insurance assignment. We request that our fees be paid in full on your first visit andeach visit thereafter. We do not participate in managed care or preferred provider organizations. We donot promise that any insurance company will pay our fees as charged to you. You must clearly understandand agree that you are charged directly and are personally responsible for all services rendered to youinour office. As a service to you, our office will complete any necessary reports and forms to help youcollect from your insurance company.
Usual and customary rates
Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of your insurance company’s determination of usual and customary rates.
The adult accompanying a minor and the parents (or guardian) are responsible for full payment
Life Wellness Centre requires a 48-hour notification of appointment cancellation. If this notificationis not received, by signing below you understand and agree that you will be charged for the entire scheduledappointment fee and billed immediately. Thank you for reviewing our Financial Policy. Please let us know if you have any questions or concerns. I have read the Financial Policy. My signature below indicates that I both understand and agree to this Financial Policy. The amount will not be billed to any insurance company.
I have read the Financial Policy. My signature below indicates that I both understand and agree to this Financial Policy. The amount will not be billed to any insurance company.
New Patient Registration Form
(All information is confidential)
Check which most accurately describes your condition
List all injuries you have had (i.e minor ones, childhood falls, contact sports, broken bones, etc.)
List all auto accidents you have had.
List medications you are taking and for what condition. :
