How did you incur this injury?
Auto: Work: Other:
Patient Name:
Last Name: First Name:
Address:
City: State: Zip:
Phone No:
Soc. Sec. No.:
Employer:
Employer Phone No.:
Primary Insurance Co.:
Policy Holder (Insured) :
Insurance Address:
Policy No.: Group No.:
Co-pay: Deductible:
Secondary Insurance Co.:
Policy Holder (Insured) :
Insurance Address:
Policy No.: Group No.:
Co-pay: Deductible:
Primary Care Physician:
Address:
City: State: Zip:
Are you currently involved in a law suit in regards to this injury? Yes No

PAYMENT AND ASSIGNMENT OF BENEFITS:
It is the policy of this office to collect co-pays at the time of treatment. Self pay
patients will be required to pay $250.00 at the time of the initial evaluation and must
make payment arrangements for the remaining amount prior to their next appointment.
Any account placed with an outside collection agency will accrue an additional charge
by signing the following I am stating that I understand this policy. I also understand
that I authorize this office to furnish my designated Administration or Intermediaries
any necessary information concerning my present medical condition. I authorize all
claims to be made directly to this office and I understand that I am financially
responsible to the physician for any charges not covered by my insurance.

SIGNATURE:
Date: