PFHL Group Registration Request Form
Groups are scheduled on a first-come-first-served basis. Groups are generally covered by most insurance companies (please call yours to verify coverage). The fee for group is $50 (this is the amount we bill to your insurance company), but the amount allowed by most insurance companies is usually less. The amount we charge for patients who don't have insurance and wish to pay out of pocket is $40 per group session. Some of our groups/workshops in 2020 will be offered free of charge, and those will be marked as such in the group/workshop description below.
Email address *
Which group(s) would you like to attend?
Patient Name:
Your answer
Patient Date of Birth:
MM
/
DD
/
YYYY
I understand that once my appointment is scheduled, I will be expected to attend unless I provide at least a 24-hour advanced notice otherwise.
I understand that if I do not provide at least 24-hours advanced notice, or if I fail to show up for a group, it will result in a $30 no show/late cancellation fee.
By typing your name below, you certify that you have read and agree to all the policies outlined above, and agree to be held by the consequences of these acknowledgments. (Please type the full legal name of the person completing this form. By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.)
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Providers for Healthy Living, LLC. Report Abuse