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HOME > Welcome Center > New Patient Health History Form
In order to provide you the best possible wellness care, please complete this form
Nature of Injury
Name of the Insured _____________________________________________
I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's signature _______________________________________________
Spouse's or guardian's signature __________________________________