Welcome to Vitality Health’s Family! Complete the information below as accurately, truthfully, and complete as possible. We are glad to welcome you to the Vitality Health family, and want to make sure you receive the best care and services for YOU. The more we know about you the better we can serve you. All patient information is kept confidential, if Vitality Health would ever need to share your information, we would request your written consent prior to sharing. Thank you for choosing Vitality Health!
Today’s Date: / Reason for Visit:
How did you hear about Vitality Health: / Referred by:
First Name: / Last Name:
Address:
City: / State: / Zip:
Mobile Phone: / Other Phone:
Mobile Appointment Reminder (please circle one): Yes No
Email Address:
Email Appointment Reminder (please circle one): Yes No
Birthdate (MM/DD/YYYY): / Age:
Sex (Circle One): / Male / Female / Other / If select other please clarify:
EMPLOYMENT INFORMATION
Employer:
Occupation:
Primary Physician:
Name:
Emergency Contact
Name: / Address:
Phone: / Relationship:
Medications: / Allergies:
FINANCIAL POLICY:
Thank you for selecting Vitality Health for your wellness needs. We are honoured to be of service to you, your friends, and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept all major credit cards and cash, care credit.
A $25 fee will be assessed to all accounts for NSF or returned checks
I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.
Patients that no call/no show or cancelation without 24-hour notice may be subject to a $25 fee on his/her account.
I have read and understand all of the above and have agreed to these statements.
Patient Signature Date:
Patient Forms/Patient Information Sheet/08/17/15