Patient Information and Consent

Patient Name(Required)

Legal First Name Legal Last Name

Preferred First Name(Required)

Patient Demographics

Permanent Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender(Required)

Male

Female

Birth Date(Required)

Marital Status(Required)

Married

Unmarried

Email(Required)

Emergency Contact Information

Contact Name(Required)

Phone#(Required)

Relationship to Patient(Required)

Patient Consent for Treatment(Required)

I voluntarily consent to any and all health care treatment and diagnostic procedures provided by San Marco Health & Wellness, Inc. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can me made as to the results of the treatments or examinations at San Marco Health & Wellness, Inc

Financial Policy and Disclosure(Required)

The Financial Policy and Disclosure is to help us provide the most efficient and reasonable health care services. Therefore, it is necessary for us to have a Financial Policy and Disclosure stating our requirements for payments of services provided to patients. Patients are responsible for the payment pf all services provided by San Marco Health & Wellness, Inc. at the time services are rendered.

Patient Information and Consent

San Marco Health & Wellness, Inc.