Phone First Name * Last Name * Email Address * Cell Phone Number * Home Phone Number Street Address * Postal Code * Date of birth * YYYY-MM-DD City * Gender * Male Female Other Family Physician Extended Health Care Plan Insurance Company Name Policy Group Number Policy Holder Name Certificate / ID Number Policy Holder Date of Birth YYYY/MM/DD Type of Appointment: * Physiotherapy Pelvic Floor Physiotherapy Acupuncture Naturopath Massage Therapy Chiropractor Consent for payment and insurance billing * I fully understand and expressly agree that I will be personally responsible for the full cost of services received from ECO Physiotherapy. If I have insurance, I acknowledge it is my responsibility to keep track of my insurance coverage or request statements of account from ECO Physiotherapy. If I incur any costs above and beyond my coverage, it is my responsibility to pay. If my insurance company allows electronic bill submissions, I consent for ECO Physiotherapy to directly bill my insurance company online. I also consent for my insurance company to pay ECO Physiotherapy directly. I consent for online submission *****If my claim is not instantly approved, but comes back pending or rejected. ****** I understand that I have 2 options. One is to pay in full or if I choose to wait for a response from the insurance I will leave a credit card on file. (A pending claim could be paid to the clinic or payment could go to you. In the case of the claim being paid to you, you are responsible to pay the clinic). If I have provided my Credit Card number and I authorize ECO Physiotherapy to charge the Credit Card, if I do not turn over the funds within 4 weeks of the treatment date or within 7 days of a phone call from ECO Physiotherapy. ECO Physiotherapy reserves the right to add 4% monthly interest on unpaid balances until fully paid. I am fully aware that there is a 24 hour cancellation policy, and if I provide less than 24 hours notice, do not show up, or arrive late, ECO Physiotherapy reserves the right to charge full price of the originally scheduled visit that was missed. I also understand it is my responsibility to keep track of my appointments.
