We believe it is in our patient’s best interest to: *

- Not give lab results over the phone or without a consultation - Not prescribe any medication without a consultation - Never prescribe narcotics - Not accept Medicare - Not accept Medicaid patients age 40+ - A consultation without insurance is $90 (effective 01/01/2021) and any other services rendered are additional prices. A consultation without insurance, for lab results only is $45 (effective 01/01/2021.) - If you have insurance, the prices vary depending on the benefits of your personal plan.

I have read and understand these policies.

Appointment and Walk-in Policy *

- Clínica Médicos accepts walk-ins at any time. - Walk-ins can be subject to wait times up to multiple hours at a time. - Appointments will be given priority over walk-ins. - Appointments become walk-ins if patient checks in 15 minutes late. - If you arrive more than 15 minutes early to your appointment, you will not be prioritized until the scheduled appointment time. - Patients should call front desk 15 minutes before original appointment time to inform of a late or canceled appointment. - After three missed appointment times the patient in question will not be allowed to make future appointments, but will be accepted as a walk-in.

I have read and understand these policies.

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you have medical insurance? *

Yes

No

Claims Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Parent/Guardian

First Name

Last Name

Parent/Guardian's Date of Birth:

MM

DD

YYYY