Patients Legal Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Telephone *

(###)

###

####

Work Telephone

(###)

###

####

Ethnic Group (Select One)

Hispanic

Non-Hispanic

Race (Check all that apply)

Asian

Black

White

Native Alaskan

Pacific Islander

American Indian

Employment Status (Check One)

Full Time

Part Time

Retired

Seasonal

Self-Employed

Student (Full Time)

Student (Part Time)

Emergency Contact *

First Name

Last Name

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Home Phone *

(###)

###

####

Emergency Contact Cell Phone

(###)

###

####

I understand and agree to the following general responsibilities *

Financial options are extended to me based on the information I have provided.

I am responsible as the patient or patient’s guarantor for full payment of services rendered at the time of service, including medicinary, lab work and tests, and physician ordered add-on lab work and tests.

I am responsible for providing all accurate and thorough documentation required to support any discounts I am receiving.

I acknowledge that I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize Sun Acupuncture & Holistic Clinic, Inc. to release information necessary to secure payment.

There will be a flat fee of $50 for any appointment not canceled within 24 hours of that appointment.

I understand that Sun Acupuncture & Holistic Clinic, Inc. is a cash based practice and accepts all major credit/debit cards (Visa, Mastercard, Amex, Discover).

I am responsible for inquiring with my insurance company whether out-of-network acupuncture is covered.

If applicable, I am responsible for requesting an itemized receipt (Super Bill) from Sun Acupuncture & Holistic Clinic, Inc.

I am responsible for submitting all required documents to my insurance carrier for the purpose of receiving any reimbursement for services rendered.

I authorize release of information in my medical history to my insurance carrier as needed. This release applies to support for insurance billing process only.

I certify the above information is true and correct to the best of my knowledge *

YES

Patient (18 years or older)

First Name

Last Name

Parent, Guardian, Financially Responsible Party

First Name

Last Name

Date *

MM

DD

YYYY