Would you like to switch to the accessible version of this site?
Don't need the accessible version of this site?
In order to provide you the best possible wellness care, please complete this form
Nature of Injury
*If an auto accident, please provide:
Name of the Insured _____________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and
charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be
immediately due and payable.
Patient's signature _______________________________________________
Spouse's or guardian's signature __________________________________
10:00 am-6:00 pm
9:00 am-1:00 pm