Dr. Timothy L. Gardner, DPM
Patient Information
Insurance Information
Responsible Party
Emergency Contact Information
Medical Information
Family History
Medications/Pharmacy Information
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.