Disclaimers

CONFIDENTIAL INFORMATION PLEASE FILL IN ALL PORTIONS OF THIS FORM

Name *

First

Last

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Age *

Marital Status *

Single
Married

Employed By *

Occupation *

Work Phone

Whom may we contact in case of emergency? *

Emergency Contact Phone *

Disclaimer: I, the undersigned, agree that any information, communication and consultations with Jessicca Rogers and Encompass Reading are for educational, spiritual and entertainment purposes only. This intuitive reading is not intended to be a replacement for medical care or emotional or mental health counseling. Spiritual intuitive coaching and healing is one aspect of whole health. You are encouraged to work proactively with your entire health care team for your highest and best good. Jessicca Rogers and Encompass Reading accepts no liability or responsibility for any actions or decisions any client chooses to take or make based on his/her consultation.

POLICY REQUIRES PAYMENT AT TIME OF SERVICES

I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible. Refunds will not be given for treatments deemed "unsuccessful”. I also understand that if I suspend or terminate my care and treatment, any fees for professional service rendered me will be immediately due and payable. Further more, any charges, fees or court costs incurred as a result of collection efforts will be added to my account balance.
The patient is ALWAYS responsible to call 24 hours prior to the scheduled appointment time to reschedule or cancel. Failure to do so will result in a $ 38.00 charge to the patient for the missed appointment. NSF checks that are returned to us will automatically mean a charge to the patient account of $35. The patient will be responsible to replace the amount of the check in addition to the $35 Non-Sufficient Funds amount. The patient is ALWAYS responsible for payment of all charges incurred.

I certify that I have read and understand the above policies. I guarantee payment of all charges incurred.

Patient Signature *

Date *

Parent/Guardian Signature

CONFIDENTIAL INFORMATION PLEASE FILL IN ALL PORTIONS OF THIS FORM

POLICY REQUIRES PAYMENT AT TIME OF SERVICES

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CONSENT TO TREATMENT