Patient Information Form

Dr. Timothy L. Gardner, DPM

Please correct the errors described below.

Patient Information

At Least Last 4 Digits

Insurance Information

    Please upload a file

    Add secondary insurance

    Responsible Party

    Emergency Contact Information

    Medical Information

    Add additional procedure

    Add additional allergy

    Add additional

    Add additional procedure

    Family History

    Medications/Pharmacy Information

    Add additional medication

      Please upload a file

      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.

      Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

      Your information will be encrypted.