Client Acknowledgement Form

Notice of Privacy Practices

I acknowledge that I have received, read and understood the Notice of Privacy Policy of v-ray.health. The Notice describes how my personal information received by v-ray.health may be used or disclosed by the v-ray.health  and my right to access this information.

Authorize to Release Medical Information

I understand and agree that v-ray.health may use and disclose my personal health information to help provide healthcare, to handle billing, insurance and payment, and to take care of other health care operations. I also authorise v-ray.health to send electronic communication which may contain protected health information to either my e-mail account or personal health record.

Payment Responsibility

I understand that all charges are due at the time of service, and that there are no refunds on consultations and/or treatments. I agree to pay v-ray.health for all charges for the treatment and/or consultation provided to me, or my dependent.

Cancellation Policy

I acknowledge that I have read and understood the cancellation policy of v-ray.health i.e.

If I choose to cancel within 24 hours of my appointment (including weekends) then I agree to pay the price in full.

By booking the v-ray.health services, I acknowledge that I understand and will adhere to the Privacy, Payment, and Cancellation Policies.