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Patient Data

Mailing Address

Accident Information

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Type of Accident

Patient Condition

Insurance Information

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*If an auto accident, please provide:

Assignment and Release

Name of the Insured _____________________________________________

I certify that I, and/or my dependents(s) have insurance coverage with ______________________ (Name of Insurance Co.) and assign directly to Dr. Thomas T. Mang all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health car information and my disclose such information to the above-name insurance co. and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Date of Last

Have you ever:

Family History

Habits

Have you ever suffered from:

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Office Hours

DayOpenClose
Monday8:00 am7:00 pm
Tuesday8:00 am7:00 pm
Wednesday8:00 am7:00 pm
Thursday8:00 am7:00 pm
Friday8:00 am7:00 pm
SaturdayBy Appt.By Appt.
Sunday8:00am12:00pm
Day Open Close
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00 am 8:00 am 8:00 am 8:00 am 8:00 am By Appt. 8:00am
7:00 pm 7:00 pm 7:00 pm 7:00 pm 7:00 pm By Appt. 12:00pm

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