l be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): —,relt--epey ftJ Patient or Legal Guardian Signature: *Please refer to our website: columbladoctors.o

l be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): -TE,Firiezy 11.1 — p Patient or Legal Guardian Signature: Date: Feb • H-10_01 *Please refer to o