Registration Information

Name                                            

Address                                         
                                                     
                                                     

Home Phone                                 
Cell Phone                                     

Email                                             

Date of Birth                                 

Is your health:

Excellent     Good     Fair     Poor

Please disclose any health concerns.
                                                      

Have youtried to quit smoking before?
If yes, explain:                                
                                                       
                                                       
                                                       

Number of Years Smoking             

Amount smoked per day
                                                      

Indicate all that apply:

Cigarettes     Pipe    Cigar    Chew

Brands Used
                                                      
                                                      





Credit Card Payment Authorization Voucher

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By obtaining the electronic form you authorize Allegheny Psychological & Counseling Services to charge your credit card based on the information provided below.  This information is treated with full confidentiality.

Please Indicate Credit Card to Charge   Discover      MasterCard      VISA Patient Name:                 ___________________           Credit Card Number:         ________________________         Name on Card:                 _______________________   Expiration date:               _________________________ Balance due:                   _________________________ Amount paid:                      ____________________ Submit Credit Card Information to the following link. billing@allegheny-psychological.com

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