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New Patient Registration Form

New Patient Registration Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

Additional Information

Contact Information

We will Email Statements, Reminders, and Lab Results. Please Initial to Accept.

Insurance Information

Responsible Party Information

ASSIGNMENT OF INSURANCE BENEFITS: I understand Evolutionary Health Care is billing my insurance companies as a courtesy. I authorize direct payment to Evolutionary Health Care of any insurance benefit. I understand the pre-authorization is not a guarantee of payment, and that I am financially responsible for any charges not paid by my insurer and I agree to pay any unpaid balances on my account no more than 90 days after date of service. In the event that payment in full for charges incurred is not paid within 90 days. I agree to pay $2.50 per billing cycle until the balance is paid in full. I understand that if my bill is not paid within 90 days my account will be forwarded to Collections. I agree to pay all costs of collection including a 50 percent collection fee, attorney fees, court costs and interest at the rate of 1.5 percent per month.

By selecting the I agree box, I consent to signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting I agree using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. By electronically signing below, I acknowledge the understanding and acceptance of the terms and conditions set forth in this E-Signature Agreement.
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