Patient Information

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EMPLOYMENT INFORMATION

RESPONSIBLE PARTY INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

We accept most insurance. However, participation may vary by plan and insurance company so please check with your insurance plan administrator. With regard to the Affordable Care Act (Obamacare), it is your responsibility to contact your insurance company before your appointment to make sure we accept your specific plan.

EMERGENCY INFORMATION

AUTHORIZATION

I authorize the release of any medical information necessary to process claims for payment. I permit a copy of this
authorization to be used in place of the original. I authorize direct payment of benefits to the physician for services
rendered. I realize I am responsible for payment of charges not covered by insurance. I certify that the information I
have reported with regard to my insurance coverage is correct.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

GENERAL CONSENT FOR MEDICAL TREATMENT

I understand that I have the right to make informed decisions about my health care treatment. I understand that Pineapple Health-Rejenesis specializes in Integrative and Preventive Medicine. I further understand that Dr. Kevin Chan is a recognized specialist in this area. I agree to have Dr. Kevin Chan and his providers and staff do tests and treatments they believe are needed for my care, including my annual physical. These may include but not limited to vital signs, ekgs, spirometries, x-rays, scans, expanded lab tests, allergy testing, lifestyle modifications, physical therapies, acupuncture, medications, hormone replacement therapies, as well as nutritional and herbal supplementations. I know other treatments or tests that may have more risks will be explained to me so I can give informed consent for them if I need them.

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