New Patient

New Patient Form

    Client Info


    standard messaging rates apply


    standard messaging rates apply


    standard messaging rates apply

    Patient Info



    Patient Medical Info











    *Accepted files: .png, .jpg, .gif

    TREATMENT AUTHORIZATION and INFORMATION/PHOTO RELEASE

    FINANCIAL POLICY

    Payment is due at the time services are rendered. A deposit may be required at the time of scheduling a treatment procedure. Payment may be made by cash, check, accepted credit cards, or pre-authorized payment services (Care Credit). Please advise us in advance if you have any questions or concerns regarding our payment policy.

    By signing this document, I ackowledge that I (the owner or agent) am financially responsible for all charges related to documented patient(s) on my record, and I understand the hospital's financial policy. I also acknowledge that the above information and statements are accurate.

    My name typed in the box below will be accepted as a legal electronic signature