Consultations - Masters-Center BodySmart Wellness Hypnotherapy Philip Holder PhD Wing Chun Certification Marie Holder MD Psychiatry Medical Hypnotherapy Certification Medical

Consultation Form

Step 1 of 3 - Welcome

Mail To:
680 Heacock Rd, Suite 204
Yardley, PA. 19067
215-493-1204
www.BodySmartWellness.com

Online Form

All information must be filled out completely before seeing the Doctor

Parents of minors must sign in the appropriate areas.

IMPORTANT INSTRUCTIONS Please submit your paperwork 48 hours (business hours) prior to your scheduled appointment so that your provider has time to review your information prior to your arrival. It is to your advantage to have your paperwork completed before coming to your appointment. This will save time and allow for better use of your therapy and/or consultation time. The Doctors normally have a full schedule so if you begin late due to incomplete or missing paperwork, your appointment may still need to end at the scheduled time.

Please submit only once. If you submit your form and later find that you have made an error, we can correct the error when you arrive for your appointment.

Filling out this form takes about 10 minutes on average. You will be asked for a list of medications and supplements that you are taking or have taken over the last two years. If you have that list available before beginning, it will speed up the process.
Thank You For Your Cooperation

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Date * Required
MM slash DD slash YYYY
Name * Required
First Last
MI
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Day Phone * Required
Eve. Phone
Cell Phone
Email * Required
Date of Birth * Required
Reason(s) for Visit * Required
How did you hear about us * Required
Reason For Consultation Visit * Required

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Payment

     Whether paying with cash, check or credit card it is required that we have a valid credit card on file. If the credit card that you are using is that of someone else, their information (address, phone number, email, etc.) must also be included on our credit card form. The patient, client or customer in signing this form acknowledges that any unpaid balances or other money owed may be charged to this card if their account is not current. This includes charges for missed appointments. Payment for services are due either at the time services are provided or prior to that time depending on the program you have selected unless other arrangements are approved in advance by the office management in writing. Since we set aside 2 hours for most initial appointments, all new patient's cards will be charged prior to that initial visit so that payment has posted by the date of that appointment. Excluding calls made for the sole purpose of scheduling an appointment(s) telephone calls/consultations lasting more than 5 minutes are billed as an appointment. Please make an appointment to discuss your case, review labs etc. (Provider's time and knowledge are their stock and trade). Note: There is a $50.00 charge for checks returned un-payable for any reason or for credit card charges denied. This document authorizes BodySmart Wellness to bill your credit card.

Hold Harmless

     Signer accepts responsibility for payment of fees. Client/Patient holds harmless, indemnifies and agrees for his/her self and his/her heirs and assignees not to sue BodySmart Wellness LLC., Dr. Philip Holder, Dr. Marie Holder and any staff or associates arising out of his/her participation & affirms that he/she is participating of his/her own free will. The patient/client/student/customer will be held responsible for any reasonable legal fees incurred by the provider in the collection of money owed or any damage caused to the provider financial or otherwise. If any part of this agreement is deemed unenforceable all other parts of this agreement remain in full effect.
No pets are allowed in the office building.     THIS IS A TOBACCO FREE OFFICE

Consultation Payment Policy

A fully refundable fee of $50 is billed for all half-hour consultations. The perspective patient/student/customer, will have the option to either: (1) Receive a refund of the $50 consultation fee, or (2) He or she may apply the $50 fee to any program selected.

To Qualify For Your Refund: Consultation Refunds are subject to the following terms:

1. The perspective patient/student/customer, must attend the consultation, arriving at the BodySmart Wellness/Masters Center Offices at the agreed to appointment time.

2. Standard BodySmart Wellness/Masters-Center Consultation Registration form(s) must be fully completed 48 hours prior to the appointment, unless other arrangements have been made in writing, in advance, regarding completion of the form(s).

3. The credit card of the patient/student/customer, will be charged the $50.00 fee the day the appointment is made. (We accept MasterCard and Visa Only)

4. If the perspective patient/student/customer needs to change his or her appointment time and/or date, prior notice of 24 hours is required. This time slot was specifically set aside for the perspective patient/student/customer and it is usually impossible for us to fill a slot at the last moment.

5. Out of courtesy for the person who's appointment follows the perspective patient/student/customer's consultation, it is important that the perspective patient/student/customer, be on time for his or her appointment. Lateness of 15 minutes or more may be considered a missed appointment at the discretion of BodySmart Wellness/Masters-Center.

6. If a perspective patient/student/customer schedules an appointment and fails to attend their scheduled consultation, the $50.00 fee will not be refunded.

It's just that simple. Your consultation costs you nothing after refund or credit!
Credit Card Authorization
Must be completed for our files even if using another method of payment

Required: Please supply your credit card number and expiration date (MasterCard or Visa). Initial appointments will be charged to this card unless other arrangements are approved by management in writing. As well, outstanding balances will be charged to this card under the following circumstances: 1. When you select any early pay discount 2. If your card is your regular method of payment, 3. If your check for payment is returned as uncollectible, 4. If you leave the office when services are rendered without making payment (unless other arrangements have been made in advance in writing) 5. If an appointment is missed without 24 hours prior notice.
Name as it appears on card * Required
Credit Card Number * Required
Expiration Date * Required
Security Code * Required
Please provide the address to which your card statement is mailed if different than the address you provided above. If it is the same, answer yes in the box below.
My address is the same * Required
- Yes
- No
Address If Different * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please attach a photo of yourself to be included in your patient chart/folder. If you do not have one, we will be happy to take one when you arrive for your appointment
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
In submitting this document/form I acknowledge that I have read and agree to all of the terms and content of this agreement and take full responsibility for payment. Typing my name below is considered my electronic signature.
Full Name * Required
Date * Required
MM slash DD slash YYYY
If purchaser is a minor, parent or guardian must fill out the boxes below.
Full Name
Date
MM slash DD slash YYYY
Type the letters you see into the box below and click ‘Submit’

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