• Emergency Contact

  • Employment

  • Referral

  • Date Format: DD slash MM slash YYYY
  • Payment

  • American Express
  • Signature, Privacy & Terms

  • I understand that all medical costs incurred by me are my responsibility; including any charges my insurance fails to pay. I also understand that I am responsible for any collection and/or legal efforts that may be necessary on my account.
  • I authorize payment of medical benefits to the physician for services provided.
  • This field is for validation purposes and should be left unchanged.

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