Patient Information

Name *
Name
Address *
Address
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Birthdate:
Birthdate:
(Circle the highest level achieved)
Employment Information
Employer Address:
Employer Address:
Work Phone:
Work Phone:
In Case of Emergency
Name 1
Name 1
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Financial Policy
Thank you for selecting Physician’s Plan Weight Management for your health care needs. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, MasterCard and checks. I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.
Date:
Date: