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.