PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

PATIENT HISTORY

REFERRING PHYSICIAN INFORMATION

EMERGENCY CONTACT INFORMATION

I certify that the above information is true. By signing below I hereby authorize the release of information necessary to file a claim with my insurance
company and I assign benefits otherwise payable to me to the doctor indicated on the claim. I also understand that I am responsible for all denied
claims, co-pays, deductibles and co-insurance amounts as indicated by my insurance whether collected at time of service or not. I understand it is
ultimately my responsibility as the insured to understand the details of my insurance benefits.