REGISTRATION FORM

Body-Mind-Spirit Podiatric Center

Please correct the errors described below.

PATIENT INFORMATION

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Brian K. Bailey or insurance company to release any information required to process my claims.

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.

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