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Patient Information

  • Patient Policy Payment is due in full at the time of service ($165 initial - $55 followup). We do not process insurance claims out of the office and therefore insurance cards are not accepted at the time of your visit. We do accept cash, personal checks, or credit card (Mastercard / Visa.) There is a $40 charge for all returned checks. A receipt will be given (if requested) at the time of payment so that you can submit it to your insurance company on your own to request reimbursement. Signature & Date:
    I understand the above payment policy and agree to it.
  • If you wish to pay your account with a credit card, please provide the information here.

  • Records Release I hereby authorize Dr. Ronald H Johnson to release any of my medical information to any referring doctor as necessary, to my insurance company as necessary, and to the responsible party as needed and as requested. Signature & Date:
  • Please print, sign, and bring with you on your visit to our office.