Client Registration Form
*Take a picture with your phone of your cards and prescription and upload them here easily.
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.