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Client Update Form

Please complete all fields that we may need to update on our end.

Patient Date of Birth
Month
Day
Year
Payment & Insurance Information
How will you pay for services?
Insurance
Self Pay
Responsible Party
Who is financially resposible for this patient?
Self
Other
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I understand and accept the contract terms as stated above. I have been given the opportunity to read this agreement and all related documents in full and in my own time. I have also been offered the opportunity to have any matters contained therein explained or clarified, as well as the opportunity to take independent advice prior to entering into this agreement. I acknowledge that I am contractually bound by this agreement, and that I am liable for fees for services due to the services perform

50 East Rivercenter Boulevard, Suite 435, Covington, KY 41011  |  859-474-6440
© 2023 Momentum Counseling, LLC

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