PLEASE BRING YOUR INSURANCE CARD FOR PROPER
SUBMISSION TO YOUR INSURANCE CARRIER.
I, the undersigned have insurance coverage with the above mentioned Insurance carrier(s) and assign directly to
Lakewood Chiropractic Clinic., all medical 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 hereby authorize Lakewood Chiropractic Clinic., to release all information necessary to secure the payment
of benefits. By checking this box I authorize the use of this electronic signature for my insurance submissions.