Option Weight Loss Clinic

Patient Intake Form

Financial Policy:

Thank you for selecting Options Weight Loss Clinic. We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. please be advised that payment for all services will be due in advance.

I agreed that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney`s fess and court costs.

I have read and understand all of the above and have agreed to these statements.

All statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. if i willingly withhold knowledge from my treating surgeon and clinical practitioners, I accept fully liability from any consequences arising.