Patient Registration Form

Patient Registration

Getting To Know You


Insurance Information


Financial Responsibility


CREDIT CARD PAYMENT AUTHORIZATION


I

, hereby authorize The Salerno Centerto charge my credit card for services

rendered and/or products supplied for a period of one year from the date below. It is my responsibility to notify of any changes regarding this credit card authorization.

Name on Card
Signature/Date

I attest, to the best of my knowledge, the above information is accurate and true.

Signature