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8365 Church St, Gilroy, CA 95020
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+ (408) 710-6547

Phone Numbers

Emergency Contact

Insurance

Assignment And Release

I certify that I, and/or my dependent(s), have insurance coverage with:
and assign directly to Dr.
all insurance benefits, if any, otherwise payable to me for services rendered. I understand
that I am financially responsible for all charges whether or not paid by insurance. I authorize
the use of my signature on all insurance submissions.

The above named doctor may use my health care information and may disclose such information to the
above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services
and determining insurance benefits or the benefits payable for related services. This consent will end
when my current treatment plan is completed or one year from the date signed below.

Signature Of Patient, Parent, Guardian, or Personal Representative (Please write your signature in the box below)

Accident Information

(if applicable)

Patient Condition

Type Of Pain:
SharpBurningDullTinglingThrobbingCrampsNumbnessStiffnessAchingSwellingShootingOther

Does it interfere with your:
-WorkSleepDaily RoutineRecreation

Activities or movements that are painful to perform:
-WorkSittingStandingWalkingBendingLying Down