FORM: Consent Only Client Signature

PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:

Name:

Home Address:

Email:

Home Phone:

Work Phone:

Occupation:

Date of birth:

S.S.#:

HOW DID YOU HEAR ABOUT OUR CENTER?

Payment Information

Type of Credit Card:

CC #:

Exp:

CID:

Billing Address: Same as Home Address

Street:

City

State

Zip Code

Phone

I authorize any BeWellRx LLC to charge my credit card for services and therapeutics that may be performed as part of my participation.

Patient Name (please print)

Patient Signature

Today’s Date