Send An Email

contact@ewingmentalhealthllc.com

Ewing Mental Health LLC

Self Pay Agreement

Fill out and submit the form below with the correct information.

SELF PAY PATIENT PAYMENT AGREEMENT



untiled
Untitled

The patient certifies that he/she read and agreed to the forgoing, received a copy thereof, and is the patient, the patient’s representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.
PATIENT NAME