CLIENT CONTACT INFORMATION

Date:

Name:

Address:

City: State: Zip:

Home Phone: Cell Phone:

Email:

Social Security#:

Date of Birth:

Estimated date of admission:

EMERGENCY CONTACT INFORMATION

Name:

Relationship:

Address:

City: State: Zip:

Home Phone: Cell Phone:

Email:

Payment Information for Prescriptions or other Personal Purchases

Please supply Credit Card information for payment for prescriptions or other personal or incidental purchases made on your behalf by The Sanctuary at Sedona.
You may pay for these purchases by personal check prior to your departure from The Sanctuary by contacting the Office Manager Monday-Friday prior to leaving.
Unpaid purchases will be charged to the Credit Card indicated below.

Credit Card Information:

Name as it appears on card
Card Type
Card Number
Card Expiration Date
Card Security Code
Billing Address
(associated with the card)
City/State/Zip
Phone Number
(associated with the card)
Amount to be charged
Signature
Email for receipt

Acknowledgment of Financial Responsibility – Promise to Pay Agreement – Insurance

Client Information:

Client Name: Date of Birth:

Responsible Party Name:

Address, City, State, Zipcode:

Home Phone: Work: Cell:

Email:

By signing this agreement I acknowledge and confirm that I am personally liable for the cost of my stay and services at The Sanctuary at Sedona paying The Sanctuary at Sedona directly amount in cash (US currency) via one of the approved payment options.

The Sanctuary will directly bill your insurance to cover all or part of your Program Fee. If we can bill your insurance provider and receive an acknowledgment from that provider of coverage, you will only be responsible for that amount of the Program Fee not covered by your insurance including all deductibles and co-pays.

Arrangements regarding the amount you need to pay on admission to cover the portion of the Program Fees not covered by your insurance were made with you prior to admission.

I understand any payment returned by my banking institution for “Insufficient Funds”, “Stop Payment”, “Account Closed” or any other reason will immediately cause the account to become delinquent and thereafter placed in a collection status which may include referral to a collection agency. If this occurs, I promise to pay all attorney fees and other reasonable collection costs and charges necessary for the collection of any amount not paid when due. I understand that, if my account is referred to a collection agency, the collection fee is ordinarily eighteen percent (18 %) of the total outstanding balance due, for which I will be responsible in addition to the principal debt due and payable.

I have carefully and completely read this agreement and fully understand the purpose, intent and effect of this agreement. I have voluntarily executed the agreement by action of my own free will.

Client Signature:

Date:


Deposit and/or Payments

Please use this form to make payments for reservation deposits and any balances due.
PATIENT NAME:
ADMISSION DATE:

Payment Information

FIRST NAME:
LAST NAME:
EMAIL:
ADDRESS:
CITY:
STATE/PROVINCE:
ZIP/POSTAL CODE:
AMOUNT:
REASON FOR PAYMENT:
CREDIT CARD TYPE:
CREDIT CARD NUMBER:
EXPIRATION DATE: