Patient Entrance Form Welcome To Khouri Chiropractic And Health Solutions, Llc Page 5
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6Khouri
Chiropractic
&
Health
Solutions
LtC
Doctor's Lein
I
hereby understand that I
am
directly and fully responsible
to Khouri Chiropractic
&
Health Solutions, LLCfor all
professional
bills submitted for services
rendered me and this
agreement
is made solely for Khouri
Chiropractic
Health Solutions LLC's
additional protection and in consideration of pending payment.
I understand that payment is expected at the time services are
rendered.
_
(Initials)
If coverage for services are denied by insurance carrier, I understand lam financially
responsible to Khouri Chiropractic
&
Health Solutions, LLCfor balance in
full.
_
(Initials)
If
J
am on an extended payment plan appoved by Khouri Chiropractic Staff, I will make timely
payments not to exceed 30 days between payments and no less than 25% of my total balance
including that day's
services.
_
(Initials)
Patient's Signature ~
_
Cancel/ Reschedule Appointments
At Khouri Chiropractic, we strive to accommodate as many patients as possible with covenant
office hours to best serve
you.
We also realize unexpected events occur when patients need
to cancel or reschedule an appointment.
As a courtesy, please notify us with as much notice
as possible, preferably 24 hours, if you are unable to make your scheduled appointment.
Please help us keep our "no penalty policy" for late notice cancellations with a courtesy call so
we may
fill
cancelled appointment times with patients in need of immediate care.
Running Late
for an
Appointment?
Please call our office if you will be arriving late for a scheduled appointment.
Most times we
can still accommodate patients. In some instances, such as with massage] we may need to
reschedule for a later time/date.
Please call for your
options.
Your cooperation in this matter is greatly appreciated.
______
, agree to notify Khouri Chiropractic if I'm unable to keep a scheduled appt.
(Initials)
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