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Patient Information


Emergency Contact Information


Insurance Information


Legal Representative of Patient

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Patient History


Surgical History


Consent for Treatment


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Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)

NOTICE OF PRIVACY PRACTICES Revised 6-01-2020


NOTICE OF PRIVACY PRACTICES Revised 6-01-2020 Signature

INFORMED CONSENT FOR MEDICATION


MEDICAL / PSYCHIATRY FOLLOW UP VISITS:


Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)
Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)

CONSENT & AUTHORIZATION TO RELEASE INFORMATION

If there are other parties that may assist in your therapy, and you believe it would be helpful for your therapist to  contact them regarding your treatment, please read carefully and complete this document. 

The following is an authorization for the stated parties to consult with one another regarding your treatment process.  Information shared is for the sole purpose of facilitating maximum care to you as the client. Please provide the  necessary information and your signature with today’s date as indicated below.


Signature of Guardian, Parent, Personal Representative: describe your authority to act for this individual (power of attorney, healthcare surrogate, guardian, etc.)

Step 2

Click the PatientAlly link to sign-up for Patient Ally . From there you can book your appoint , fill the necessary paperwork, and view your records and payments. 

INSURANCE

WE ACCEPT MOST INSURANCES INCLUDING MEDICARE AND MEDICAID. FEES ARE BASED ON A CONTRACTED RATE WITH YOUR IN-NETWORK INSURANCE COMPANY AND YOU WILL BE INFORMED OF THIS FEE PRIOR TO YOUR SCHEDULED APPOINTMENT.

Pricing

WE ACCEPT ALL FORMS OF PAYMENTS CASH, $CASH-APP, PAY-PAL, VENMO, ZELLE, APPLE PAY AND ALL MAJOR CREDIT CARDS

$ 300
INITIAL CONSULTATION
  • $125 FOLLOW-UP VISITS

U-First Healthcare Plans

Annual Physical and Preventive Health Plan Office visits when you need them.

U-FIRST PREMIUM CARE

$ 99 Monthly
  • 6 Sick Visits & 1 Annual Wellness Visit
  • No Co-pays, No Deductibles.
  • Medication Management
  • All in office services and all in office tests covered
  • Labs and Routine Health Screenings

U-FIRST CARE PLUS

$ 79 Monthly
  • 3 Sick Visits & 1 Annual Wellness visit
  • No Co-pays. No Deductibles.
  • Medication Management
  • All in-office services and all in-office tests covered
  • Labs and Routine Health Screenings

U-FIRST CARE

$ 49 Monthly
  • 2 sick visits & 1 Annual Wellness Visit
  • No Co-pays, No Deductibles
  • Medication Management
  • All in office services and all in office tests covered
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