BRICK: 1680 Highway 88, Brick, NJ 08724

BARNEGAT: 849 West Bay Ave Barnegat, NJ 08005

HOLMDEL: 721 N. Beers St, Suite 1B Holmdel, NJ 07733

PHONE: 732-458-7900 FAX: 732-458-7902
Holmdel and Barnegat by appointment only

PRIVACY DISCLOSURE STATEMENT: Please list any person that we may discuss your care with:


I authorize J.C. Orthopedic, Inc. to bill my insurance/s on my behalf. I understand that I am responsible for any co-pay, co-insurances, or deductibles that apply. I understand that J.C. Orthopedic will attempt to verify benefits, but that is not a guarantee of payment. I understand that I am ultimately responsible for any balance owed. I also consent for treatment to be given to me that has been prescribed by my physician. I acknowledge that no guarantee has been made about the outcome of my treatment.