Client Registration Form

CLIENT INFORMATION
MEDICAL INFORMATION
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INSURANCE INFORMATION

OFFICE POLICIES AND RELEASE OF MEDICAL INFORMATION
I authorize and consent to the release of any medical information to (1) any insurance company through which I claim benefits and (2) any physicians as requested by any such insurer or physician for the purpose of treatment, payment, and healthcare operations. I authorize the assignment of all medical and procedural benefits to which I am entitled including Medicare, Private Insurance, group benefits, and other health plans to Pink Regalia, LLC. I understand it is my responsibility to pay all collection costs and reasonable attorney’s fees in the event this account is turned over to an attorney for collection. I also request Pink Regalia to contact me in writing or telephone regarding recalls, product modifications, and/or reorders for products Pink Regalia may have provided.

PLEASE COMPLETE INFORMATION BELOW

TO CONFIRM CONSENT – OFFICE POLICIES & MEDICAL INFORMATION, Thank you!