Electronic Prescribing of medications can only be performed if a valid pharmacy is given

I consent to the taking of photographs of me (or my dependant) before, during, and after my surgery, which may be used for documentation, resident education, testing, credentialing and online public education, publications / presentations given by Dr. Sirota for which they may be of benefit. My name will not be identified along with my pictures in any publication (other than for submission to insurance companies for financial approval). If photographs include my face, my identity will likely be recognizable.  Jewelry, tattoos, distinctive clothing, and/or other features may also reveal my identity. I also give Dr. Sirota permission to discuss my case with any other health care providers involved in my care or those who might become involved with or beneficial to my care.

I, the undersigned certify that I (or my dependant) have insurance coverage with and assign to Dr. Sirota all insurance benefits, if any, otherwise payable to me for services rendered. I understand that Dr. Sirota does not participate in my insurance and I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Dr. Sirota to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.