I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of con dences and it is my responsibility to inform this o ce of any changes in my medical status.

I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance bene ts to the o ce.
I understand that where appropriate, credit bureau reports may be obtained.