Dr. Timothy L. Gardner, DPM
Patient Information
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Emergency Contact Information
Medical Information
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Family History
Medications/Pharmacy Information
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I hereby request medical treatment and authorize payment to Dr. Timothy L. Gardner, DPM.
I understand that I am responsible for any portion of my bill not covered by my insurance company and give Dr. Gardner's office the right to collect my balance within 90 days or I understand that I will be sent to a collections agency and possibly face legal action.
I hereby authorize the release of medical information for insurance claims purposes.
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