Please check the following health condition associated with mom, dad, grandparents.
I certify to the best of my knowledge that all of the information above is correct.
I understand that I am financially responsible for all chargers not pain by insurances (such as deductibles, non-covered services, co-pays, co-insurances). I hereby aurthorize the doctor to release all information necessary to secure all insurance benefits and hereby assign all insurance benefits to Foot Care Specialists, PLLC. I authorize the use of this signature on all insurance submissions. This signature gives my permission for treatment by Dr. LaWanda Bailey-Rayner.
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