PATIENT FIRST NAME MIDDLE INITIAL LAST NAME
DATE OF BIRTH
PATIENT STREET ADDRESS APARTMENT
CITY, STATE, ZIP HOME PHONE BUSINESS PHONE

IN CASE OF EMERGENCY, WHO DO WE CONTACT?
NAME RELATION PHONE
I understand payment is due at time of treatment.

________________________ ____________
signature date


INSURANCE INFORMATION
The Healing Experience 5150 Roswell Rd. Atlanta, GA 30342
Phone: (404) 255-3110 Fax: (404) 497-9796 gtgunter@bellsouth.net