Personal Information
Treating Physicians
Insurance Information
Emergency Contact
I hereby consent to and authorize the performance of all treatments, surgery, and all medical services by the Center for Foot Surgery Oxnard. I accept full financial responsibility for all medical/surgical services performed on my behalf that are not covered by my insurance company. All co-payments, deductibles and non-covered services are due at the time of service, unless prior arrangements have been made. I hereby authorize the provider and assistants to release all information necessary acquired in the course of my examination and/or treatment to secure payment for services. I hereby authorize my insurance company to pay benefit directly to the Center for Foot Surgery Oxnard.

Medical History

Social History
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Surgical History

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