|Will you use health insurance? *|
|Emergency Contact Name and contact info: *|
|May Dr. Turnbull thank the person who referred you?|
The information on this form is true to the best of my knowledge.
I authorize my insurance benefits to be paid directly to Dr. Turnbull.
I understand that I am financially responsible for any balance.
I also authorize Dr. Turnbull and my insurance company to exchange information required to process my claims. *