The Blossom Method requires 24 hours prior notice for all appointment cancellations. If prior notice is not provided, patients will be charged a $150 fee.

We will send you a copy of this form that you can complete and scan back to us. Please provide your credit card information on the form before your first session.

Also, please note that all co-insurance payments are the responsibility of the patient, and should be paid no later than the time of each session. Any unpaid balances will be charged to the credit card provided on file.

To arrange payment, please contact our biller at (219) 476-0352 Ext # 6031.

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties concerning the privacy and confidentiality of any information submitted through this form.