Please enable JavaScript in your browser to complete this form.Patient InformationPatient Name *DOBAgeSexMFMarital StatusAddress *City, st Zip *Tel *Alt TelAlt Tel typeEmail *Spouse or Parent NameTel Referring Physician Tel .I understand that I am financially responsible for all charges regardless of whether I have any coverage from a health insurance company or any third party. I have read the financial policy presented to me and posted in the waiting room and agree to this financial policy.Signature of patient or responsible party * Clear Signature Date *.The 'Notice of Privacy Practices" is available in the office for my viewing. With my Consent, Valley Orthopedic Technology may use and disclose Protected Health Information (PHI) in order to carry out treatment, payment and health care operations. With my consent, this office may also call my home and leave a message; send reminders/requests for appointment by mail; speak to other members of my household by telephone.Signature of patient or responsible party * Clear Signature Date *Signatory' Name *Submit
