Patient Registration Form
Thank you for choosing Cooper Center for Metabolism. Please respond to the following questions.
Name: Middle Initial
Date of Birth:
Mailing Address (Street) :
Mailing Address (City, State and Zip Code)
Phone (cell number):
Emergency contact phone (relative or close friend / relationship partner if ever an emergency):
Authorization & preference to leave messages from this office (choose all that apply):
phone message, cell
phone message, other
text message, cell
e-mail message (note: electronic communication only permitted via Hello Health secure portal. If you wish to communicate electronically - please request activation code)
health care provider
friend or family member
athletic trainer, coach, personal trainer
Responsible Party (responsible for payment)
PLEASE READ & ACKNOWLEDGE THE FOLLOWING:
1. Payment is due in full at the time of service. We accept major credit cards, checks and cash
2. You will be billed in full for appointments that are not cancelled 3 full business day in advance. Note: For missed lab appointments without a 24 hour notice - you will be charged a flat fee of $25. We require a credit card on file for all patients. This card will be charged for failure to cancel your follow up appointment 3 business days in advance or your lab appointment 24 hours in advance. Your signature on this form includes your agreement to this charge being applied for cancelled appointments and no-shows outside of the cancellation policy guidelines.
Appointment cancellation policy - to avoid a full appointment fee cancellation charge:
To cancel a Monday appointment notify us by the prior Wednesday
To cancel a Tuesday appointment notify us by the prior Thursday
To cancel a Wednesday appointment notify us by the prior Friday
To cancel a Thursday appointment notify us by the prior Monday
To cancel a Friday appointment notify us by the prior Tuesday
If you have missed your lab appointment we do not automatically cancel your follow-up appointments. You are still expected to show for your follow up and if you plan to cancel that appointment it is your sole responsibility for cancelling the appointment.
3. Seattle Performance Medicine is not a participating provider (non-network) and we do not bill insurance. It is your responsibility to check with your insurance carrier as to coverage for non-network providers. We provide a claim form for you to submit to your insurer for reimbursement. We do not guarantee reimbursement for charges incurred at Seattle Performance Medicine. Please be aware of your particular plan"s requirements for out of network services.
4. We charge a fee for obtaining blood and processing specimens . This fee is separate from the lab fee. The lab will bill your insurance directly for testing run on the specimen. Your insurance carrier will notify you of any remaining balance. Some insurers require a specific lab or in-network provider to order and process labs. If you are unaware of your coverage for lab testing, please check with your insurance provider to verify your coverage.
I acknowledge that I have read this document in its entirety. I understand and accept the policy regarding insurance coverage, cancellation policies and payment responsibility as explained herein by Seattle Performance Medicine. I permit you to charge my credit card on file for any missed appointments without required notice as described above.
Checking this box serves as my signature and acknowledgement of payment responsibility
Please print & sign completed form (this page), bring to appointment or fax to (206) 632-4576. Signature of patient or if minor, legal guardian (in space below):
PLEASE BE SURE YOU ALSO COMPLETE THE NEW PATIENT HEALTH HISTORY FORM
Should be Empty: