If an auto accident, please provide:
Name of the injured
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Spouse or Guardian's signature
Family members-Past and present health conditions(Example: heart disease, cancer, diabetes, arthritis, etc.)
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