NEW PATIENT AGREEMENTNew Patient Agreement • November 14th, 2018 • South Carolina
This is an Agreement between New South Family Medicine, LLC, a South Carolina limited liability company, located at 1365 Broadcloth Street Suite 203, Fort Mill, SC 29715, and you,
New Patient AgreementNew Patient Agreement • February 7th, 2018
We are happy to have the pleasure of meeting your child’s dental needs. Please read carefully and sign the following new patient agreement
ContractNew Patient Agreement • June 18th, 2024
New Patient AgreementNew Patient Agreement • September 28th, 2010
Thank you for choosing us to provide you with dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. This financial agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask.
New Patient Agreement Form – Updated October 2022 Please read through ALL the information below before signing. The surgery will retain a copy in your records. NAME: DATE OF BIRTH Routine appointments and emergency appointmentsNew Patient Agreement • August 19th, 2019
For routine GP telephone consultations I can book up to one week in advance (7.30-8.30am) or on the day. There is a limit to the appointments available and I may need to call back. The appointment system is subject to change. Note receptionist are not permitted to book patients for face to face appointments with the GP.
New Patient AgreementNew Patient Agreement • December 3rd, 2019
New Patient AgreementNew Patient Agreement • April 29th, 2021
Mahalo for choosing Moon Physical Therapy as your health provider - we truly appreciate your support and will do our absolute best to provide you with exceptional health care solutions for many years to come.
New Patient AgreementNew Patient Agreement • April 22nd, 2019
By signing below I understand and agree that I am financially responsible for all treatment started, and I will pay on the day that the services are rendered to me. Any change in my treatment plan either by my choice or by necessity may change the fees originally quoted. I understand that whenever possible, Benson Family Dental Care will inform me of any changes in advance. I understand there may be unforeseen changes that may occur.
New Patient Agreement Form – Updated 28 Aug 19 Please read through ALL the information below before signing. The surgery will retain a copy in your records. NAME: DATE OF BIRTH Routine appointments and emergency appointmentsNew Patient Agreement • August 19th, 2019
For routine GP appointments I can book up to one week in advance or on the day. There is a limit to the appointments available and I may need to call back. The appointment system is subject to change
New Patient AgreementNew Patient Agreement • January 5th, 2016
Below is a list of ideas and recommendations to aid you in the success of your orthodontic treatment. Good luck, you will be great! If you have any questions, please be sure to contact our office
Bing MD New Patient AgreementNew Patient Agreement • April 23rd, 2023
In this agreement, “Bing MD” refers to Bing Wu (“Dr. Wu”), a family physician licensed in Alberta by the College of Physicians and Surgeons of Alberta.
New Patient AgreementNew Patient Agreement • September 28th, 2018
New Patient AgreementNew Patient Agreement • February 27th, 2024
Thank you for choosing us to provide you with dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest and forthright. This financial agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask.
Jonathan Lebolt, PhD, LLC ~ New Patient AgreementNew Patient Agreement • April 10th, 2024
• Let me know how you think treatment is progressing. Feel free to ask me any questions, and let me know what’s helpful or unhelpful.
Jonathan Lebolt, PhD, LLC ~ New Patient AgreementNew Patient Agreement • September 29th, 2024
• Let me know how you think treatment is progressing. Feel free to ask me any questions and let me know what’s helpful or unhelpful.
New Patient AgreementNew Patient Agreement • October 26th, 2012
THIS AGREEMENT CONTAINS IMPORTANT INFORMATION ABOUT MY PROFESSIONAL PRACTICES AND BUSINESS POLICIES. PLEASE REVIEW IT AND ASK ME ANY QUESTIONS THAT YOU MAY HAVE ABOUT THIS DOCUMENT OR ANY OTHER DOCUMENT OR FORMS THAT YOU MAY FILL OUT WHILE WORKING WITH ME.
New Patient AgreementNew Patient Agreement • August 5th, 2016
I, the undersigned, understand that the procedures that I will receive in the course of this evaluation or treatment will consist of diagnostic and psychotherapeutic interviews conducted/facilitated by the employees and contractual staff of Woodbridge Psychological Associates, PC (the Practice). Although the Practice’s employees and contractual staff may also have professional roles or affiliations with other organizations (e.g., the Community Services Board, or The University of Virginia), services rendered by the Practice are offered independently, and are not provided under the auspices of these other affiliations and organizations.
New Patient AgreementNew Patient Agreement • February 13th, 2017
NEW PATIENT AGREEMENTNew Patient Agreement • November 25th, 2020
Thank for your interest in becoming a patient of Oubre Medical. This document serves as an outline for what your membership will grant you access to, as well as any additional policies and details you should be aware of. If you have any questions regarding your membership or this document, you may always contact us at 512.829.1104 or admin@oubremedical.com.
NEW PATIENT AGREEMENTNew Patient Agreement • April 15th, 2020 • North Carolina
David Bruce Mabry, M.D. and any subsequent medical doctor engaged by MyMD Direct, PLLC, who specializes in internal medicine, will deliver medical care on behalf of MyMD Direct, PLLC, at the address set forth above (each a “Physician” and collectively the “Physicians”). In exchange for certain fees paid by You, MyMD Direct, PLLC, by and through its Physician(s), agrees to provide Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
