Tricity Family Medicine & Urgent Care

SAME DAY PHYSICAL EXAM & OFFICE VISIT POLICY

Due to recent changes in your insurance payment policy, they REQUIRE your physical exam/wellness care and your illness/follow up care to be addressed in two separate visits. This will ensure the time and attention required for each visit is met by the provider.

By Signing below, I acknowledge I have read and understood the above policy regarding Same-Day Wellness Care & Illness care policy. I understand, if I DO NOT adhere to this policy, I will be subject to the charges NOT covered by my insurance carrier.

I understand: *

PRESCRIPTION REFILL POLICY

By signing below, I acknowledge I have read, understood and agree to adhere to Prescription Refill Policy.

I understand: * Patient's First Name * Patient's Last Name * Patient's Date of Birth * Parent/Guardian or Responsible Party Name Relationship to Patient