New Client Agreement Form: Initial Functional Medicine ConsultationNew Client Agreement • June 1st, 2020 • Massachusetts
It is our great pleasure to welcome you to this customized Functional Medicine Initial Consultation session! Please read and sign the following. If anything is unclear, please don’t hesitate to ask. This Agreement is made today between the Health Educator and the Client (both as named above).
NEW CLIENT AGREEMENTNew Client Agreement • March 11th, 2021
* You may rest assured that your email address will never be shared with any third party. It will only be used by FUNNYBONES to notify you of special events and promotions – and to contact you, should the need arise, while your dog is in our care.
New Client AgreementNew Client Agreement • May 30th, 2014
Owner’s Name Address City State Zip Home Phone Cell Phone Business Phone Email How did you find out about us? Is any one else authorized to pick up your dog?
New Client AgreementsNew Client Agreement • April 29th, 2009
check date by 2PM Central time. Funds will be debited from client accounts one day prior to check date. Next Day and expedited transactions will incur additional charges.
NEW CLIENT AGREEMENTNew Client Agreement • August 22nd, 2010
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail, and my practice is in general accordance with HIPAA policies. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents a
New Client AgreementNew Client Agreement • April 17th, 2019 • Indiana
This agreement is established on {$_datetime|date_format:'%D'} between Vortex Web Solutions LLC (referred to hereinafter as "Company") and {$organization} (referred to hereinafter as "Client") .
NEW CLIENT AGREEMENTNew Client Agreement • April 30th, 2006
* You may rest assured that your email address will never be shared with any third party. It will only be used by FUNNYBONES to notify you of special events and promotions.
New Client AgreementNew Client Agreement • September 13th, 2021
Owner’s Name Address City State Zip Home Phone Cell Phone Business Phone Email How did you find out about us? Is any one else authorized to pick up your dog?
New Client AgreementNew Client Agreement • February 1st, 2012
In addition to the general terms and conditions listed on the back on this form, client hereby agrees to the following bank authorization.
New Client AgreementNew Client Agreement • August 29th, 2019
Unless other arrangements have been made, payment is due at the time of service. If using medical insurance, copay/coinsurance payment, if applicable, is due at the time of your appointment. Cash, check and credit card are accepted. Checks can be made payable to LeeAnn Weintraub, MPH, RD.
New Client AgreementsNew Client Agreement • April 29th, 2009
check date by 2PM Central time. Funds will be debited from client accounts one day prior to check date. Next Day and expedited transactions will incur additional charges.
Denney Veterinary Service New Client AgreementNew Client Agreement • September 9th, 2024
