Responsible Party

Name of Person Responsible for this accesse

Relationship to Patient

Address

Home Phone

Cell Phone

Drivers License#
					
Birthdate
					
Finalized Institution

Employer
					
Work Phone
					
SS#/SIN

Is this person currently a patient in our office?
					
Yes
					
No

For your reference, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash
					
Personal Check
					
Credit Card
					
Visa
					
MasterCard
					
I wish to discuss the office payment policy.

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