Informed Consent to Treatment
I certify that I’m the patient or legal guardian listed on this new patient form. I have read/ understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of above information to this office, Bare Motion Integrated Health. I authorize this office and its staff to examine and treat my condition as the practitioners see fit. I hereby authorize the practitioner to release all information necessary to any insurance company for the purpose of claim reimbursement of charges incurred by me. I grant the use of my electronically signed statement of authorization with my electronic signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I’m responsible for timely payment of such services. I understand and agree that health/ accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
- Payment on the day by EFTPOS or Cash.
- A missed appointment fee of the full appointment price may be applied at the discretion of Bare Motion Integrated Health if less than 24 hour’s notice is given.
- You may cancel your appointment by calling the office on (08) 9284 6662 or sending an email to firstname.lastname@example.org.
- Please arrive no later than 5 minutes prior to your scheduled appointment.
- This office does not bill Insurance Companies direct.