XanoGene - Anti Aging, Genomic & Holistic Clinic
 
ORIENTATION VISIT
 
 
This a brief orientation face to face with one of our board certified physicians, explaining the evidence based XanoGeno approach to Anti Aging & Genomic medicine.  
This is not an evaluation visit, the cost for this visit is $75.00.
 
PATIENT REGISTRATION FORM
Last Name:
First Name:
Middle Name:
Adress:
City:
State:
Zip Code:
DOB:
Sex:
F:
M:
Marital Status:
Single:
Married:
Divorced:
Widow:
Separated:
Home Phone:
Cell Phone:
Work Phone:
Email:
Who may we thank for referring you ?:
Emergency Contact:
Relationship:
Phone:
Employer:
Occupation:
PARENT, SPOUSE, OR RESPONSIBLE PARTY (if different from patient)
Name:
DOB:
Address:
Home Phone:
Cell Phone:
Work Phone:
HEALTH THIRD PARTY PAYERIF APPLICABLE
Co. Name:
Address of Claim Center:
Name of Third Party Payer Policy:
DOB:
Policy #:
Group Name or #:
*Please present your XanoGene VIP card(s) & photo ID or third payer verification form to the receptionist.
PLEASE READ & SIGN BELOW. Welcome to our office. We are here to serve your healthcare Anti Aging & Preventive Genomics needs. We will accept your third party payer in accordance with our polices. After we have verified that you have satisfied your responsibilities and if the reason for your visit to the doctor(s) is a covered medical condition under our agreement.
I authorize and request my third party payer or company and/or government benefits to pay directly this office for services furnished to me or my dependents by said physician.
My signature authorizes the releasing of my medical information and/or my dependents to the insurer or agency or XanoGene VIP card shown necessary to pay the claim by paper or electronically.
I permit a copy of this authorization to be used in place of the original. I understand that I am financially responsible for all charges whether or not paid by the third payer agency or carrier.
I further agree that should the amount be insufficient to cover the entire medical expense, I will be responsible for payment of the difference; and if the nature of the service be such that it is not covered by the third payer agreement, I will be responsible to the Doctor(s) for payment of the entire bill.
I agree that should this account be referred to any agency or attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs. I certify that the information given by me is correct. I have read and understand all of the above and have agreed to them.
Patient’s Signature:
Date: