Patient Registration Massage Therapy                                                      (PLEASE PRINT CLEARLY) 
 
Patient’s Name: _________________________________________________________ 
                   	 First Name             	     MI      		     Last Name 

Date of Birth: ____________________     					_____Male _____ Female _____ Trans-gendered

______Single   ______ Married _____ Partnered ______Widowed   ______ Divorced   ______ Separated

Home Address _______________________________________________________________________________________________________

City/State/Zip Code: ____________________________________________________ Home Phone w/Area Code: _______________________ 

Cell Phone w/Area Code: ______________________________ E-mail address: _____________________________________________________

May we contact you by email and/or telephone?  Yes____ No_____   Which do you prefer? __________________________________________

If patient is a Minor, are parents __Married    __Divorced    Custodial Parent: _____________________________________________ 

Custodial Parent’s Home Phone w/Area Code: _________________________ Work Phone w/Area Code: _____________________ 

IN CASE OF EMERGENCY, contact: ______________________________________Phone Number w/Area Code: ______________________ 

Relationship to Patient: ___________________________________ 

Billing & Treatment Policy
 
The following sets forth the general billing and treatment policy of Center Point Healing. Please review this information and sign below. 
 
•	I understand that it is my responsibility to provide the office of Center Point Healing with current, accurate billing information at the time of check in and to notify the provider of any changes in this information. 

•	I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $25 NSF fee. I further understand that to rectify my account, I will be required to pay with cash, a money order, cashier’s check, or credit card. 

•	I understand that full payment is due at the time of service and that I can pay with cash, check, Visa, MasterCard or Discover card.  If I choose to tip my massage therapist, I understand this must be given in cash. 

•	I permit a copy of this authorization to be used in place of the original. 

•	I further agree to pay all collections costs, attorney fees, and other collections costs that may be incurred to enforce the collection of any amounts outstanding. 

My signature below confirms that I have read and understand these billing policies, privacy practices and my financial obligation as pertain to the health care provider, Center Point Healing.  I authorize the professional staff at Center Point Healing to treat me and use my personal health information for healthcare operations.
 
_________________________________________________________________________________________________
Patient’s Signature    											Date 
 
OR

___________________________________________________________________________________________________ 
Legal Guardian to Patient (if patient is minor or incapable of signing) 					Date