Clergy Pay Consent Form

Clergy Pay Consent Form

Patient Name:                                                                                                                                   

Financially Responsible Party

Name:                                                                  Telephone#:                                                          

Billing Address:                                                    Email:                                                                    

Signature of Clergy                                                     Date

Emapth Healing and Wellness LLC ~ 2150 South 1300 East Suite 500, Salt Lake City, UT 84106

www.EmptahHealingandWellness.com

Clergy Pay Consent Form

Patient Name:                                                                                                                                   

Financially Responsible Party

Name:                                                                              Telephone#:                                                          

Billing Address:                                                    Email:                                                                    

Signature of Clergy                                                     Date

Emapth Healing and Wellness LLC ~ 2150 South 1300 East Suite 500, Salt Lake City, UT 84106

www.EmptahHealingandWellness.com

Patient Name:                                                                                                                                   

Financially Responsible Party

Name:                                                                              Telephone#:                                                          

Billing Address:                                                    Email:                                                                    

Signature of Clergy                                                     Date

Emapth Healing and Wellness LLC ~ 2150 South 1300 East Suite 500, Salt Lake City, UT 84106

www.EmptahHealingandWellness.com