PATIENT INFORMATION

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POLICY HOLDER

(If Diffrent Than Above)
(Please Tick One)
Primary Number (Please Tick One)

INSURANCE INFORMATION:

(PLEASE TICK INSURANCE COMPANY)
(If you are a minor, this must be signed by your parent guardian.)

I, the undersigned, hereby authorize payment of insurance benefits to the attending Physician for the serice/s rendered to the patient named on this form, together with the release of any medical information necessary to process a medical claim.

I, understand that I am solely responsible for full payment of all cost/s incurred in the event that my insurance company does not pay, as well as all legal cost from an agency collection if charges are not paid and any expense that may be charged for collection of an outstanding account/s.

Emergency Contact