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Patient Information

AIDIN WELLNESS FINANCIAL POLICY

June Franzen, Nurse Practitioner, appreciates the confidence you have shown in choosing her to provide for your healthcare needs.  The service you have elected to participate in implies a financial responsibility on your part.  The responsibility obligates you to ensure payment IN FULL of our fees the day of service.  I agree to pay Aidin Wellness/June Franzen, the full and entire amount due the day of service.

• Payment for ALLservices are due at the time of your appointment.  We accept cash, credit/debit/HSA card payments
• There is a 5% discount for paying for your appointment with cash.  Use of credit/debit/HSA card will notqualify for the discount.
• Initial patient visit is $79 for in-person or telehealth appointment.

You are responsible for the cost of all labs, medications, and treatment/services.  If you have insurance coverage, your labs/tests may be covered, that is totally dependent on your personal agreement with your insurance company.  I understand and take full responsibility for any amounts not covered by my insurance provider.  Refunds or credits are not permitted on any medications or treatments received. If payment is made with non-sufficient funds (NSF) a $40.00 fee will be added above and beyond the original charge.

Consent for treatment:

I authorize June Franzen, APRN to provide medical services today and for all future appointments.  I understand I am financially responsible for all of the charges.  This consent will stay in effect until I discontinue receiving health care at Aidin Wellness.

Surgical History:

Family History:

Medications

Do YOU have a personal history of the following?

( X ) Check all that apply.

PREVENTITVE MEDICAL CARE: