Birth Date _____________ _____ Male______ Female______
Home Phone ( ) Daytime Phone ( )
Social Security #Cell Phone ( )
Marital Status: Now Married____/ Never Married____/ Divorced____/ Widowed____/ Sig Other____/
Employment Work AddressOccupation Type of Insurance: Independent_____/ PPO_____/ HMO_____/ Medicare_____/ None_____/
Name of Insurance Company
Referred By or How You Found Us
IF SOMEONE OTHER THAN PATIENT IS RESPONSIBLE FOR PAYMENT:
NameRelationship Employed BySocial Security # Home Phone Work Cell
PERSON TO CONTACT IN CASE OF EMERGENCY:
INITIAL APPOINTMENTS ARE NOT TO BE CANCELLED WITHIN 5 BUSINESS DAYS OF THE APPOINTMENT. THESE VISITS ARE SIGNIFICANTLY LONGER THAN ROUTINE VISITS AND CANNOT BE FILLED ON SHORT NOTICE. ROUTINE APPOINTMENTS ARE NOT TO BE CANCELLED WITHIN 24 HOURS. THERE WILL BE A CHARGE FOR LATE CANCELLATION OR MISSED APPOINTMENTS.
PAYMENT IS DUE AT TIME OF VISIT BY EITHER CASH, CHECK, OR CREDIT CARD.
WE REQUIRE you or others accompanying you to NOT wear colognes, perfumes, scents, essential oils, or scented lotions to the office.We keep a scent free office for people with sensitivities.
PLEASE SIGN AND RETURN AT LEAST ONE WEEK PRIOR TO YOUR APPOINTMENT.
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE & FOLLOWING INFORMATION IS CORRECT. I UNDERSTAND THE CANCELLATION POLICY AND PAYMENT POLICY. I HEREBY CONSENT TO MEDICAL AND HOMEOPATHIC TREATMENT BY DR. JEFF D. LESTER, D.O.
Email Policy & Agreement Email is a welcome way to consult with our office regarding problems and questions.
However, no emergency material is to be communicated by email. Because of the time required for our Physician to read and respond to emails communications, the following fees will apply: Half-page = $20.00 / Full-page = $40.00
There is no charge for the Staff to receive emails regarding setting up appointments or sending remedies.
Remedies by Mail Homeopathic remedies can be sent to you by mail, by the following procedures;
1) Call or email us stating which remedies are needed, ie- name & dose (daily/booster/high).
2) Include your credit card number if not already on file. For timeliness & efficiency,
arrange to have your card on file (your number will be privacy-protected).
3) Shipping & handling in most cases is a flat-rate of $4.
Most major credit cards accepted (Visa, MasterCard, American Express, etc)