Healthcare Appointment Slip

HEALTHCARE APPOINTMENT SLIP

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Appointment Details

Appointment Date:    Time:

Pre-Appointment and Administrative Notices

Arrival Instructions: Please arrive at least prior to the scheduled time to complete registration and any required screening.

Cancellation / No-Show Policy: I understand that if I fail to appear for my scheduled appointment without providing timely notice, a cancellation or no-show fee may be charged. I acknowledge that fees not covered by insurance are my responsibility and may be collected prior to or at the time of future appointments. No-show fee amount: $

Appointment Reminders: Please indicate preferred reminder method(s): Phone Call Text Message Email

Medical Summary (brief)

Authorizations and Acknowledgments

Billing and Release for Scheduling: I authorize the clinic and its agents to release or obtain medical and insurance information necessary to schedule my appointment, process claims, and obtain payment for services. I authorize my insurer to pay benefits directly to the clinic for covered services.

Privacy Practices Acknowledgement: I acknowledge that I have been offered or provided the clinic's Notice of Privacy Practices describing how my protected health information may be used or disclosed. I understand that appointment reminders or test results may be left on my voicemail or communicated to the contact information I provided.

By checking the box below, I confirm that the information provided on this Appointment Slip is true and accurate to the best of my knowledge and that I accept the administrative policies herein. I acknowledge and agree

Additional Instructions / Notes

Sign Now