I authorize My Omni Housecalls, consent for medical treatment. It is my understanding that I may withdraw this consent at anytime. It is my understanding that my insurance will be billed and I am responsible for any amount due after payment.  I understand that I may be asked to pay a copay, deductible, or any other fees based on my insurance carrier that I am responsible for. I agree to pay all reasonable attorney fees and collection cost in the event of any payment defaults. I also acknowledge that I have read My Omni Housecalls, office and Financial Policies.