Common Contracts
1 similar Patient Agreement contracts
ContractPatient Agreement • April 5th, 2023
BEARDEN CHIROPRACTIC CENTER 5633 OAK STREET EASTMAN, GA 31023Phone (478) 374-1111 Fax (478) 374-1913 REGISTRATIONDate: Phone: Patient: Last Name First Name InitialStreet Address: City/State/Zip Code: Sex: □ M □ F Age: Birthdate: □ Single □ Married □ Widowed □ Separated □ Divorced Social Security #: Email: Insured’s Name: Last Name First Name Initial Patient Agreement:ASSIGNMENT AND RELEASE I irrevocably authorize and assign to you, the chiropractic provider, the right to receive direct payment from my attorney or any Insurance company which may become obligated to pay me any sums. The Patient(s) grant(s) to the Provider a Limited Power of Attorney to receive funds, negotiate any drafts or checks and execute any documents related to payment for services rendered to me. _Signature of Insured/Guardian Date Present Complaints (Please circle the appropriate ones) Headache Feet/Hands Cold UnbalancedMental dullness Depression FaintingLoss of memory Rib pain Blurred visionDizzy
