PATIENT UPDATE INFORMATION

 

Full Name:
Signature:
Date of birth:
Telephone Number:
Medical Changes:
Employer Name:
Employer Address:
Insuranced by:
Date:
How do you plan to pay for your treatment today?

Cash
Credit Card
Check
Finance Plan

I, , am aware that if I do not pay my estimated “co-pay” at the time of service, Dr. Hammond and Dr. von Roenn are not obligated to honor the Fee Schedule provided by my insurance company. I also understand that I am fully responsible for my account and the contract with my insurance company is between my-self and the insurance company. If, after 90 days, my account balance is not paid in full, Drs. Hammond and von Roenn may begin charging my account an interest rate of 1.5%.

Please print this form and bring it with you to your appointment

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