I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the use of the above information for my treatments at Greenleaf Healthcare.. I authorize this office and its staff to examine and treat my condition with my active involvement. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon my care or treatment.
Our policy for missed appointments: A charge of 50% of the visit cost, for a No-show or Non-cancellation less than 12 hours before the appointment time.
I authorize Greenleaf Healthcare to use the card on file to pay for any outstanding balances, including copays, coinsurance, and all other account charges under patient liability.