Please fill out the following in its entirety. If submitted correctly a Submission Confirmation Page and email will be received.

APPOINTMENT DETAILS: For initial office visits, all items listed below must be received by our office prior to being seen. Patients should
arrive at least 30 minutes before their appointment time in order to complete the registration process.
• All new patient paperwork
• Insurance card(s)
• Driver license or government issued photo ID
• CD’s of all imaging & the accompanying reports. The appointment may be rescheduled if we do not have them.
• EMG & other tests related to diagnosis
For follow-up office visits, all items listed below must be received by our office prior to being seen. Patients should arrive at least 10 minutes
before their appointment time to complete the check-in process. If X-rays are being done in office prior to being seen, the patient should arrive
at least 30 minutes before their appointment time.
• Insurance card(s)
• Driver license or government issued photo ID
• CD’s of any new imaging or testing with the reports
Due to physicians’ patient load, arrival more than 10 minutes late for your appointment, may result in being rescheduled.

APPOINTMENT RESCHEDULING AND CANCELLATIONS: Please notify our office as soon as possible in the event an appointment
needs to be rescheduled or cancelled. Failure to notify our office of the cancellation at least 24 hours prior to your appointment, may result in a
missed appointment fee. Our office hours are 8:00 am to 5:00 pm, Monday through Friday.

PHYSICIAN EMERGENCY SURGERY SCHEDULE CHANGES: Please be aware that our physicians are on-call surgeons for some of the
busiest hospitals in the area. Should a physician be called away for an emergency surgery, he/she may run late seeing patients. Occasionally, an
emergency may necessitate cancelling office appointments on short notice. These types of emergencies could also affect your scheduled surgery
date/time. Every effort will be made to contact you in the event this does occur. Please be sure all contact information remains current so our
office can contact you in a timely manner.

WORKERS’ COMPENSATION: It is the patient’s responsibility to notify their Workers’ Compensation case manager of any change in
appointment date and/or time. If a case manager accompanies you to the appointment, there is a $250 charge he/she must pay at the time of
check-in for a team conference.

FINANCIAL RESPONSIBILITY: All co-pays, co-insurance, and/or deductibles are due at the time of service. If the patient does not have
health insurance or if their health insurance plan is not one with which our physicians participate, full payment for services is due at the time of
service. Please note that additional services provided in the office, such as but not limited to x-rays, reprogramming, and injections are not
included in the office visit charge. Post-operative visits are included in the insurance carrier’s global period from surgery; however, x-rays are
not. MEDICARE PATIENTS ONLY: Unless the patient has supplemental or secondary insurance coverage, you are responsible for your
twenty percent co-insurance at the time of your visit. If your visit is the result of an injury due to a Motor Vehicle Accident which led to a
liability claim, your office visit here and any surgery will be on a cash only basis. Any surgery must be paid in full prior to the day of surgery.
We do not accept letters of protection from attorneys. There is a $25 fee for any returned checks due to insufficient funds.

NETWORK PARTICIPATION AND REFERRALS: Our office will make every effort to verify your insurance prior to your visit, but it is
ultimately the patient’s responsibility to ensure we are participating in the plan prior to your appointment. If your insurance requires a referral to
see our physicians, please check with your primary care physician to see that a referral has been completed. If the referral is not received in the
office prior to your appointment, the appointment may have to be rescheduled.

DISABILITY/FMLA & OTHER FORMS: We will gladly complete forms for disability/FMLA/ or other requests. There is a $35 fee per
form each time it is completed and is payable at the time of request. Please allow 7-10 business days for completion.

PRESCRIPTION REFILLS: Requests for prescription refills must be called in at least 24 hours in advance. No refills will be called in over
the weekend or holidays. Refill requests submitted on Friday may be called into the pharmacy on Monday. Refills are given under the direction
of the physician who reserves the right to refuse a refill at any time.

By signing this document, I understand the above policies.

I, the undersigned, have third-party insurance coverage and assign directly to Fort Worth Brain and Spine Institute, LLP, 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 Fort Worth Brain and Spine Institute, LLP to release all information necessary to secure the
payment of benefits. I authorize the use of the below signature on all my insurance submissions.

If covered by Medicare, I request the payment of authorized Medicare benefits be made to or on my behalf to Fort Worth Brain and
Spine Institute, LLP, for any services furnished me by one of their physicians. I authorize any holder of information about me to
Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for
related services. I understand my signature below requests that payment be made and authorizes release of medical information
necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved
claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In
Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge,
and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based
upon the charge determination of the Medicare carrier.

I have reviewed Fort Worth Brain and Spine Institute, LLP’s Notice of Privacy Practices, which explains how my medical information
will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

I have reviewed Fort Worth Brain and Spine Institute, LLP’s Notice of Privacy Practices, which explains how my medical information
will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

The undersigned patient (“Patient”), or legally-authorized representative of the Patient, desires a physical evaluation and/or treatment at
Fort Worth Brain and Spine Institute, LLP. The undersigned voluntarily consents to such care which may include, but is not limited to,
routine diagnostic procedures, physical examinations, including but not limited to x-rays, blood draws, laboratory tests, administration
of medication and to medical or surgical treatment by physicians and staff members of Fort Worth Brain and Spine Institute, LLP, as
well as any other health care providers who may be called upon to consult or assist in the Patient’s care as judged necessary by Patient’s
treating physicians. The undersigned acknowledges that the practice of medicine is not an exact science and further acknowledges that
no guaranties have been made as to the results of Patient’s examination or treatment at Fort Worth Brain and Spine Institute, LLP. The
undersigned acknowledges that treatment at Fort Worth Brain and Spine Institute, LLP is intended to address specific episodic illnesses
or injury and is not intended to substitute for comprehensive care in lieu of a primary care physician or other specialized physician. In
order to provide the best chance for successful treatment, the undersigned accepts responsibility to follow the advice of the Patient’s
treating physician including compliance with medications, discharge instructions and follow up with all needed physicians. The
undersigned agrees that Patient shall return to the clinic or seek care in an emergency department of a hospital if Patient’s condition
substantially changes. The undersigned further agrees to hold harmless the physician and staff of Fort Worth Brain and Spine Institute,
LLP should the undersigned fail to comply with the above conditions. Patients at Fort Worth Brain and Spine Institute, LLP will be
treated regardless of race, color, age, national origin, disability or religion. Notwithstanding the above criteria, Fort Worth Brain and
Spine Institute, LLP reserves the right to refuse care to any individual for any reason at the discretion of the physician on duty.

Covered entities as the term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed
authorization from the individual or the individual's legally authorized representative to electronically disclose that individual's protected health
information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance
functions, or as may be otherwise authorized by law. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a
refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this
authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION." I understand that
prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that
refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law
without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c)
and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the
recipient and may no longer be protected by federal or state privacy laws.

By signing below, I acknowledge that there are risks associated with electronic e-mail communication, including some level of risk that the
information in an e-mail could be read by a third party. I acknowledge and agree that Fort Worth Brain & Spine Institute, LLP will not be liable for
loss of information due to technical failures on my end. I acknowledge that the use of e-mail may pose certain limitations and may not be appropriate
in certain situations. For example, I acknowledge that the nature of electronic communication may cause delays in response. Further, I acknowledge
that e-mail communication may be an insufficient mode for me to receive certain health care services. I agree to schedule an appointment if I have
further questions about my health care.

I acknowledge and agree that completion of this document does not establish a patient-physician relationship and that this form is meant only for
existing patients of Fort Worth Brain & Spine Institute, LLP. By signing below, I consent to communication via e-mail and confirm my preference to
use e-mail over other available means of communication.

Dear Patient:

The Physicians at Fort Worth Brain & Spine Institute, LLP are independent, private practice physicians. This means our Physicians
are not employed by any corporate or outside health care entity. And this means we work for YOU, not for a hospital, an
administrator, or any other corporate or outside health care entity.

In order to assure the highest quality and efficient delivery of your health care, the Physicians of Fort Worth Brain & Spine Institute,
LLP may maintain financial interests in other health care facilities and providers. Our commitment to providing the highest quality
care for our patients is paramount. Having financial interests in certain health care facilities and/or providers enables your Physician
to have additional control on the quality of care provided to you as opposed to having little control or input with corporate health care
entities. A simple example would be having an imaging study done in a specific fashion tailored to the patient’s individual condition,
rather than having to accept a “cookie-cutter” study that is done the same way for every patient, regardless of the condition being
investigated.

Decisions regarding your care are always based on your best individual medical treatment plan developed by you and your Physician.
Patients of Fort Worth Brain & Spine Institute, LLP always have the option of utilizing alternate health care facilities or providers, and
at times, this may actually be dictated by their individual health insurance plan. Regardless, your Physician and you will develop the
best treatment regimen available for your specific condition, using evidence-based “best practices.” Please feel free to discuss your
options or any questions you may have with your Physician or our staff during your visit. We welcome any questions regarding this
aspect of your patient care.

The following list includes the facilities and providers for which our Physicians maintain any form of ownership interest. As a Patient
of Fort Worth Brain & Spine Institute, LLP, you may receive care or services from any of these facilities or providers. Your Physician
may receive some form of financial benefit related to the care or services rendered by these facilities and providers, depending on the
legal ownership structure of each individual facility or entity.

• Methodist Southlake Hospital, Southlake, TX 76092
• Baylor Surgical Hospital, Fort Worth, TX 76110
• Parkway Surgical Hospital, Fort Worth, TX 76177
• Page Medical, Grapevine, TX 76051
• Vaquero Medical, Grapevine, TX 76051
• Polestar Medical Solutions, Southlake, TX 76092
• Trinity IOM, Fort Worth, TX 76104
• 117 Surgical Assistants, Fort Worth, TX 76104
• Squire Surgical Services, Southlake, TX 76092
• Fort Worth Ranch Assist, Fort Worth, TX 76109
• Myeuverse IOM, Fort Worth, TX 76102
• FW CSN Monitoring, Fort Worth, TX 76102
• Lone Star Monitoring, Irving, TX 75063
• Lone Star Neurosurgical Assistants, Westlake, TX 76262
• Select Pain Procedure Center, Fort Worth, TX 76102
• Brain Assist, Keller, TX 76248
• IONM, Keller, TX 76248

Patient Acknowledgement
I acknowledge that my attending Physician(s) has disclosed to me, at the time of initial contact and at the time of referral (A) his/her
affiliation if any, with the facilities or providers for whom, I, the patient am being referred, and (B) that he/she may receive financial
benefit related the care rendered by the facility or provider based on the individual legal ownership structure of the facility or provider.
I understand that I, the Patient, have the right to choose the providers of my health care services.

Please sign below to acknowledge the receipt of this disclosure and to indicate that you do not have any objections to using the
facilities or providers listed above.

Fort Worth Brain & Spine Institute, LLP Surgical Assistants are out-of-network with the majority of our participating
insurance company networks.
Fort Worth Brain & Spine Institute, LLP agrees to bill your insurance and accept the payment processed, normally
against your out-of-network benefits. Fort Worth Brain & Spine Institute, LLP will collect the patient responsibility
due according to the explanation of benefits. Fort Worth Brain & Spine Institute, LLP will act as my duly appointed
representative in the resolution of any unpaid charges, including acting on my behalf during any reconsideration and
appeal.
By signing below, you are acknowledging and accepting Fort Worth Brain & Spine Institute, LLP’s Notice of Nonparticipating
Providers policy and procedures.