Financial Agreement

24 HOUR CANCELLATION POLICY

Please be respectful of the time set aside for your treatment. If you need to change or cancel your appointment, be sure to make up the missed appointment within a week so that the effects of the treatment will not be interrupted. All scheduled appointments require a 24 hour cancellation notice or the patient will be charged for a full office visit.

ASSIGNMENT OF BENEFITS FOR INSURANCE

I authorize payment of benefits be made directly to this healthcare provider and I understand I am responsible for charges not covered by this assignment. I also authorize the release of any information requested to process this claim.

RETURNED CHECK POLICY

All returned checks will be subject to an additional charge of $25.