Patient Information

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Emergency Contact Information

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I Verify that the above information is factual and true to the best of my knowledge. I authorize the doctor to employ X-rays, photographs, anesthetics, medicines, surgeries, and other equipment or aids as he/she deems necessary in order to provide the proper patient care. I understand that payment, proof of insurance, and/or copay is due at the time of service.

I authorize Kirstin Care, LLC to apply benefits on my behalf for the covered services rendered. I certify that the insurance information I have provided is factual and correct.

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