PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • June 8th, 2017
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
St. Norbert College Registration Financial AgreementRegistration Financial Agreement • October 27th, 2016
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • June 8th, 2017
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • July 31st, 2018
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • June 8th, 2017
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • February 12th, 2020
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • February 12th, 2020
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
PATIENT REGISTRATION / FINANCIAL AGREEMENTRegistration / Financial Agreement • February 12th, 2020
Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER’S COMP OR AUTO ACCIDENT RELATED.
