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Which Extremity
Patient Name
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Male or Female
Emergency Contact Name
Your Employer
Marital Status
Spouses Name
Mother's Name
Father's Name
I give my permission to leave messages for appointments or account information with:

My signature indicates the above information is true to the best of my knowledge. I authorize the release of medical or other information necessary to central brace & prosthetics, for orthotic or prosthetic treatment I also authorize release of information necessary to bill insurance claim filing purposes. I understand not all items may be covered by my insurance policy. Coverage verification with my insurance carrier does not guarantee a payment from them. It is my responsibility to provide central brace and prosthetics with current and correct insurance information. I also understand I am ultimately responsible for any allowed amount not paid for or covered by insurance.
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