Common Contracts

Patient Name (Print) DOB

An Agreement • March 7th, 2018 • Indiana

• Contract Type
  An Agreement
• Filed
  March 7th, 2018
• Jurisdiction
  Indiana

Patient acknowledges that execution of this Services Agreement is an application to join Westfield Premier Physicians, LLC, medical practice as a patient. Westfield Premier Physicians, LLC, in its sole discretion, may accept or reject any Patient at any time for any reason. If Patient is accepted by Westfield Premier Physicians, LLC, this Agreement shall govern the ensuing business relationship.