BRICK: 1680 Highway 88, Brick, NJ 08724

BARNEGAT: 849 West Bay Ave Barnegat, NJ 08005

HOLMDEL: 721 N. Beers St, Suite 1B Holmdel, NJ 07733

PHONE: 732-458-7900 FAX: 732-458-7902
Holmdel and Barnegat by appointment only

Patient Name:

Guardian:

Address:

City:

State:

Zip:

Primary Phone:

Secondary Phone:

Date of Birth:

Email:

PRIVACY DISCLOSURE STATEMENT: Please list any person that we may discuss your care with:

Name:

Relationship:

What type of message may we leave on your voicemail ?

Insured's Name:

Relationship to Patient:

Insured's Date of Birth:

Employer City/State:

Workers Compensation or auto accident?

If Yes: Date of Injury

Primary Insurance:

Secondary Insurance:

Policy #

CONSENT AND AUTHORIZATION

I authorize J.C. Orthopedic, Inc. to bill my insurance/s on my behalf. I understand that I am responsible for any co-pay, co-insurances, or deductibles that apply. I understand that J.C. Orthopedic will attempt to verify benefits, but that is not a guarantee of payment. I understand that I am ultimately responsible for any balance owed. I also consent for treatment to be given to me that has been prescribed by my physician. I acknowledge that no guarantee has been made about the outcome of my treatment.

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