CLIENT INFORMATION FORM / PAYMENT METHOD CHOICES

Please print the following three pages and mail or fax completed forms to:
     Provo & Associates, PO Box 357, Corte Madera, CA 94976-0357 / fax 888-435-4016     

  The following information is necessary for emergencies, reports and billing purposes.
    Please notify us if any of this information changes. * Required

 

Printable Microsoft Word Version: Client Information Form.doc

Names of Parents:

______________________________________________________________

Name of Child:

_______________________________ Date of Birth: _________________

Name of School:

_______________________________Grade_______________________

Primary Address of Child:

Street: _____________________________________________________

City: ___________________________________ Zip: _________________

*  Name and Address of Person Responsible for Billing:

Name: ________________________________________________________

Street: ________________________________________________________

City: ___________________________________ Zip: ___________________

Contact Information (please print clearly):

 *  Home:

Mother:________________________  Father:________________________

 * Work/Cell:

Mother: ________________________ Father: ________________________

Fax:

* E-Mail:

Mother: ________________________ Father: ________________________

Mother: ________________________ Father:________________________

Referred by:

______________________________________________________________
Doctor or Other Professionals:

_______________________________Specialty:________________________

Please Briefly Explain The Purpose of Your Visit: _______________________________________________________________________________

_______________________________________________________________________________


Payment Method: Please choose one ( X ) 
(Please read Fee Schedule and Billing Policy )

______

Method I - I wish to pay by credit card.

(Must complete Credit Card Information and Authorization Form.)

 

______

Method II - I wish to pay for in person consultations "At-Time-Of-Visit." For all other expenses unable to be paid in person such as phone consultations, school observations or research I agree to have my credit card billed.

(Must complete Credit Card Information and Authorization Form.)

 

 

______

 I have already contacted Provo & Associates

______

 Please contact me to arrange an appointment

______

I have read and agree to the Provo & Associates Billing Policy dated November 1, 2008. I understand and agree to the charges related to meeting coordination, research, report reading, travel time and the 24/72 hour cancellation policy. I further understand that Provo & Associates does not accept Medical Insurance nor can it render and Diagnosis Codes for insurance purposes. Payment for services rendered is strictly my responsibility.

 

            Print name:__________________________________________________________

            Signature:___________________________________________________________ 

            Date signed:________________

 

 

 

CREDIT CARD INFORMATION AND AUTHORIZATION FORM

The Credit Card Rate is $180 per hour, plus any travel time or agreed upon additional expenses.  We will bill your credit card for each date of service and furnish you with either an email or fax confirmation.  No invoices will be sent for this payment method.  If your credit card is approved and then, for any reason, later payment is denied to us, there will be a $15 charge back fee.  (This is the fee that we are charged by our credit card company.)

Please print name as it appears on the card:  ___________________________________

____ VISA 
____ MASTERCARD
Account No.:   _________________________________________________________
Expiration Date:  _______________________________________________________
Name of Issuing Financial Institution : ______________________________________
Address of Record on this card: ___________________________________________

 

__ I wish to have an email confirmation.  Email address: ________________________

__ I wish to have a fax confirmation.        Fax number:   _________________________

 

I understand and agree to the above and wish to have services billed to my credit card unless I have paid Diane Provo directly in person.                                 

 

Signature:_______________________________________________ Date:_________

 

 Please mail completed form to
Provo & Associates, PO Box 357, Corte Madera, CA  94976-0357
or fax to 888-435-4016