Common Contracts

2 similar Patient Agreement contracts

EMPOWER FAMILY MEDICINE PATIENT AGREEMENT
Patient Agreement • June 14th, 2018 • Georgia

This is an Agreement between Empower Family Medicine, L.L.C., a Georgia professional corporation, located at 209A Swanton Way Suite 101, Decatur, GA 30030, and you, (Patient, Principal). Melissa Black M.D. (Physician) serves as an agent of Empower Family Medicine (EFM). The person indicated as Principal agrees to assume financial responsibility for the Patients indicated.

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EMPOWER FAMILY MEDICINE PATIENT AGREEMENT
Patient Agreement • June 14th, 2018 • Georgia

This is an Agreement between Empower Family Medicine, L.L.C., a Georgia professional corporation, located at 209A Swanton Way Suite 101, Decatur, GA 30030, and you, (Patient, Principal). Melissa Black M.D. (Physician) serves as an agent of Empower Family Medicine (EFM). The person indicated as Principal agrees to assume financial responsibility for the Patients indicated.

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