New Patient Intake Form

Step 1 of 4

Patient Name *

First

Middle

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Occupation

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

FINANCIAL RESPONSIBILITY *

I understand and accept that AAIM CENTER will bill the charge in effect when services are provided; that I may request a price estimate for such services; that I agree to pay for such services; and that I acknowledge and accept my personal responsibility for payment in full for billed charges. I acknowledge failure to meet my financial obligations to AAIM CENTER will result in the referral of account(s) to professional collection agencies. Should my account be placed for outside collections, I agree to pay reasonable costs and legal fees as set by the court. Authorization: I have read, or have had explained to me, the above Conditions of Admission. I understand the contents of this Conditions of Admission document. I am the Patient, the Patient’s legal representative, or am otherwise authorized by the Patient to sign for the above and accept its terms.

Patient (Guardian) Signature *