Mr. Timothy Knight

 
 7609521074 
 16:09:15 11-09-2017 
 6/6 
 Dr Scott Stewart DDS M.D. 
 26515 Weaver Summit Suite 017
Port Richardton, CA 97181 
 LAST NAME: 
 Wieczorek FIRST: Mr. Timothy Knight 
 MI 
 NA 
 STREET ADDRESS: 13300 Meteor Dr. CITY Victorville ST CA ZIP 92305 
 MAILING ADDRESS: 8309 SVL Box CITY Victorville ST CA ZIP 92305 
 PHONE: 
 CELL# 871-309-2972 SS# 530-23-7301 M/F F 
 DOB: 10/2000/08 
 DRIVERS LICENSE#: C4125420 
 MARITAL STATUS: S 
 M 
 D 
 W 
 LANGUAGE PREFERRED: English 
 I HERBY AUTHORIZE THE DOCTOR TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS. I 
 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I 
 HEREBY AUTHORIZE THIS PRACTICE TO VERIFY MY MEDICATION HISTORY. 
 SIGNATURE: 
 02/2015/15 
 SIGNED: 
 01/09/2018