What to Bring to First Visit

 

Please bring the following to your first visit with Dr. Gabby:

Print out and complete Consent for Treatment (see below) 

Photo of your Child (Hard copy)

Any prior records you would like Dr. Gabby to review (Hard copies)

Your payment is requested at the time of the visit by cash, check, Venmo or Credit Card.

Consent for Treatment

I have read and understand the office policies of Dr. Tina Gabby.  I accept, understand and agree to abide by the contents and terms of this agreement, and further, consent to participate in evaluation and/or treatment.  I understand that I may withdraw from this process at any time.

I understand that payment is due at the time of service and that I am personally responsible for all charges as Dr. Tina Gabby is not affiliated with any insurance provider.  If payment is not made at the time of service, the charges outlined above will be assessed to my credit card on file (with 3% charges added for credit card processing.)

 Name of patient (please print):_____________________________________________

 Date of birth:______________________________________________________________

 Address:__________________________________________________________________                                                            

Phone number:____________________________________________________________

 Email Address:_____________________________________________________________

Name on Credit Card:_____________________________________

Card Type:________________________________________________

Card Number:_____________________________________________

Security Code:_____________________________________________

Expiration Date:____________________________________________

 

 

_________________________________________________________

Signature of Parent/Guardian

_________________________________________________________

Date