Self Pay Agreement Form

* Required Information

Self Pay Patient Payment Agreement

I understand that I will be responsible for all charges related to the services provided to me by You First Health and Wellness Services LLC.

I understand that the charges presented to me are due in full on the day of service, unless arrangements have been made with the provider. I also understand that these charges are solely in relation to the professional services provided by the provider.

The patient certifies that he/she read and agreed to the forgoing, received a copy thereof, and is the patient, the patient’s representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.

Patient Name

Signature *

Clear

Date

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.