Participant's Name *

First Name

Last Name

Phone *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

RELEASE OF INFORMATION & ASSIGNMENT OF BENEFITS *

I hearby authorize IGT to provide clinical information requested by insurance companies to pay my therapist directly.

Yes, I understand that I am responsible for any charges not covered by my insurance company.

CANCELLATION POLICY *

Except in severe weather conditions or emergencies, a 24-hour notice is required to avoid a $50 cancellation fee.

I acknowledge this policy.

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card below for services. I understand that my information is saved on file for future transactions tn my account.

Credit Card Holder's Name *

First Name

Last Name

Phone *

(###)

###

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