Hope Medical Group


Schedule an appointment with us Make Appointment Reschedule Appointment Cancel Appointment Patient Status: New Established How did you find out about us? Patient Name: Guardian Name: (if patient is a minor) Address: Contact Number: Email Address: Method of Payment: Private Insurance Medicaid/Medicare Credit Card/Check Cash Other Requested Appointment: Month Day Year Time: AM PM Name of Physician Additional Comments: Agreement of Appointment Cancellation I understand that a 24-hour Notice MUST be given for any cancelled appointment. Should this notification not be given, there shall be a $25.00 surcharge for each of such failure. Because this shall NOT be billed to my Insurance Company I understand that I shall be responsible for these charges. I also understand that although this Practice "Walk-ins" 24 Hours, 7 days a week, PRIORITY shall be given to those with appointments (except in Medical Emergencies). Agreement of Communication I understand that as part of my healthcare Hope Medical, P.C. will need to contact me from time to time for the purpose of reminding me of an appointment, relaying the results of a test, advising me of special precautions and measures that I need to follow prior to a procedure, etc. I hereby authorize Hope Medical Group, P.C. to contact me in the following ways: Phone: Home answering machine: Office voicemail: (xxx) xxx-xxxx (xxx) xxx-xxxx (xxx) xxx-xxxx Fax: Email: (xxx) xxx-xxxx Signature of Guardian of patient: Date: mm/ dd/ yyyy Relationship to patient: