LYG Attorney Medical Lien Acknowledgement

Patient Name/Nombre de Paciente*
First Last
Patient Email*
Date of Injury
Date Format: MM slash DD slash YYYY
Date signed*
Date Format: MM slash DD slash YYYY
The undersigned being attorney or record for the above patient does hereby agree to observe all terms of the above and agrees to withhold such sums form any settlement, judgement or verdict as may be necessary to adequately protect said acupuncture provider: LYG/Dragon Eye
Attorney Name*
First Last
Attorney's signature

1809 E. Dyer Rd. #313
Santa Ana CA 92705

Fax (949) 975-0070

1809 E. Dyer Rd. #313
Santa Ana CA 92705

Attorney's signature