CHILD CONSENT OF TREATMENT

    PARENT HISTORY SHEET


    Email Address:

    Mother
    Mother's Name:

    Martial Status:

    CHILD CONSENT OF TREATMENT

    By filling out the potion below, I give consent for treatment by Dr. Donna G. Estreicher, Ph.D.

    Patient Name:

    Date:

    HIPPA PRIVACY PRACTICE NOTIFICATION

    By filling out the portion below, I agree that I have read the HIPPA Privacy Act and the Policy and Procedure Manual.

    I was offered a copy of the HIPPA Privacy Act.:

    Patient was offered a copy of the HIPPA Privacy Act and refused it.:

    Patient Name:

    Date:

    FINANICIAL RESPOSIBILITY

    If for any reason we are unable to collect the contracted rate of payment from your insurance provider, it is your responsibility to pay this amount in a timely manner.

    By filling out the portion below, you agree to comply with our policy regarding payment for services rendered.

    Patient Name:

    Date:

    CANCELLATION POLICY

    We ask that you notify our office 48 hours in advance for any type of cancellation. If there is a cancellation less than 24 hours, you will be charged $100 cancel fee regardless of your reason (except in the case of an emergency). By filling out the portion below, you agree to comply with our policy regarding last minute cancellations and/or no-shows.

    Patient Name:

    Date:

    [recaptcha]