Common Contracts

2 similar Patient Registration / Financial Agreement contracts

PATIENT REGISTRATION / FINANCIAL AGREEMENT
Patient Registration / Financial Agreement • August 21st, 2024

Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.

PATIENT REGISTRATION / FINANCIAL AGREEMENT
Patient Registration / Financial Agreement • March 22nd, 2023

Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.