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Appointment Date *
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          Guarantor (Person responsible for payment) *
          Do you have medical insurance? *
          Primary Insurance Name
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          Relationship to Guarantor *
          Primary Insurance ID Number
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          Do you have secondary medical insurance? *
          Secondary Insurance Name
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          Accept Terms *

          I authorize the medical to release any information, including diagnosis, treatment plans/records and radiographs to third party payers and/or health practitioners. I authorize and request that my insurance company (if applicable) pay directly to the medical group or medical benefits that are, otherwise, payable to me. I understand that my medical insurance may pay less than the actual bill for service or may not cover certain treatment.

           

          I hereby certify that the foregoing information is accurate and complete and that in consideration of treatment and services rendered to me or my dependents by this medical office, I accept responsibility and agree to be obligated to pay the office in accordance with its payment and credit terms and policies.

           

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          Orthopedic & Sports Medicine Center

          Office Hours:

          Monday-Friday 8:00am – 4:30pm

          Garland Office P: 972-276-0536 F: 972-276-6037

          2241 Peggy Lane Suite A
          Garland, TX 75042

          Richardson/Plano Office P: 972-675-9500 F: 972-675-9400

          2821 E George Bush Turnpike #306
          Richardson, TX 75082

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          • SELECT * FROM wzs3e_baforms_columns WHERE form_id = 2 AND `key` = 'bacolumn-26'653μs1.13KB/components/com_baforms/src/Helper/BaformsHelper.php:657Copy
          • SELECT * FROM wzs3e_baforms_items WHERE form_id = 2 AND `parent` = 'bacolumn-26' ORDER BY `column_id` ASC400μs1.91KB/components/com_baforms/src/Helper/BaformsHelper.php:676Copy
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          • SELECT `alias` FROM `wzs3e_content` WHERE `id` = :id100μs1.63KBParams/components/com_content/src/Service/Router.php:168Copy
          • SELECT `c`.`id`,`c`.`asset_id`,`c`.`access`,`c`.`alias`,`c`.`checked_out`,`c`.`checked_out_time`,`c`.`created_time`,`c`.`created_user_id`,`c`.`description`,`c`.`extension`,`c`.`hits`,`c`.`language`,`c`.`level`,`c`.`lft`,`c`.`metadata`,`c`.`metadesc`,`c`.`metakey`,`c`.`modified_time`,`c`.`note`,`c`.`params`,`c`.`parent_id`,`c`.`path`,`c`.`published`,`c`.`rgt`,`c`.`title`,`c`.`modified_user_id`,`c`.`version`, CASE WHEN CHAR_LENGTH(`c`.`alias`) != 0 THEN CONCAT_WS(':', `c`.`id`, `c`.`alias`) ELSE `c`.`id` END as `slug` FROM `wzs3e_categories` AS `s` INNER JOIN `wzs3e_categories` AS `c` ON (`s`.`lft` <= `c`.`lft` AND `c`.`lft` < `s`.`rgt`) OR (`c`.`lft` < `s`.`lft` AND `s`.`rgt` < `c`.`rgt`) WHERE (`c`.`extension` = :extension OR `c`.`extension` = 'system') AND `c`.`access` IN (:preparedArray1,:preparedArray2) AND `c`.`published` = 1 AND `s`.`id` = :id ORDER BY `c`.`lft`159μs5.13KBParams/libraries/src/Categories/Categories.php:375Copy
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