Address
Appointment reminders are a courtesy service; all patients are responsible for remembering their scheduled appointments. We require a minimum of 24-hour notice for cancellations.
Guarantor if Not the Patient (financially responsible party for minor or incapacitated adult)
Guarantor Name
Note: By providing a phone number or email address, you are consenting to being contacted at that number or address regarding your treatment or billing information. In addition, your email will be used to invite you to join our secure patient portal.
Drivers License, Passport, Non-Drivers License. Allowed file types include: jpg, png, pdf, gif, HEIC. Maximum file size allowed: 25 MB
Allowed file types include: jpg, png, pdf, gif, HEIC. Maximum file size allowed: 25 MB
Emergency Contact Information & Relationship to Patient
Insurance Information
Subscriber Name
Clear
Consent
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize You First Health and Wellness Services LLC company to release any information required to process my claims.
I give my consent.
By checking this box, I consent to receive text messages related to conversations (external) from You First Health and Wellness Services LLC. You can reply "STOP" at any time to opt out. Message and data rates may apply. Message frequency may vary, text HELP to 240-438-0325 for assistance. For more information, please refer to our privacy policy, and SMS terms and conditions on our website.