7. I understand that the use of drugs, prescribed or otherwise, the abuse of same (both past and present) or the existence of medical conditions not disclosed by myself to Dr. Gardner or his assistants may affect his recommendation as to treatment or alternative forms of treatment and |assume all risks which may exist as a result of my failure of refusal to disclose such matters prior to treatment.
8. I certify that I have read and fully understand the above consent to operation, that the explanations therein referred to were made, and that all blanks or statements requiring insertion or completion were filled in and inapplicable paragraphs, if any, were stricken in my presence and before I signed.
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.
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.