Registration From

2544 E. Washington Blvd., Suite C, Pasagena, CA 91101 (626) 398-4069

IMPORTANT

I hereby give permission to Dr. Michael Avakian to treat my feet and/or ankles medically and surgically as deemed necessary, I also authorize all insurance benifits to be paid directly to the physician. I understand that I am personally responsible for all charges incurred for professional services, Any application of insurance benefits of these charges is courtesy extended to the patient who is responsible for the account rather than the insurance company. I also understand that payment is due when professional service are rendered. The signature(s) below constitute(s) authorization for these services and agreement to pay for them in full. My signature on file is my authorization necessary to process my claim.