LYG Attorney Medical Lien Acknowledgement

  • Date Format: MM slash DD slash YYYY
  • 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's signature

MAIN OFFICE

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

Fax (949) 975-0070

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No Referral Needed

MAIN OFFICE

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