Intake Form Page ( 1 )

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If you are not the PRIMARY CARD HOLDER, we need the following information

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Assignment of Benefits, Authorization for Release of Information, and Consent

1). Assignment of Benefits: I hereby direct my Insurance Carrier(s) or Attorney to pay by check made and mailed directly to: Garlett Chiropractic Clinic, PC, 4141 NW Expressway, Suite 385, Oklahoma City, OK 73116.

2). I also understand that I am personally responsible and agree to pay, in a current manner, any balance due after payment or non-payment by my Insurance Carrier(s) or Attorney.

3). A photocopy of this document shall be considered as effective and valid as the original.

4). Consent: I give permission to the doctor and his staff to administer treatment and perform such procedures as deemed necessary in the diagnosis and treatment of named patient.

I have read and agree to the above statements
Garlett Chiropractic Clinic, PC, 4141 NW Expressway, Suite 385, Oklahoma City, OK