I also agree to notify immediately, if I cease to represent the above mentioned patient. Law Firm:_______________________________________________________________________ Address:________________________________________________________________________ City:____________________________________State_____________Zip___________________ Phone #:________________________________ Fax #:__________________________________ Attorney Signature: _______________________________________Date: ____________ NOTE; ANY ALTERATION OF THIS LIEN MAKES IT NULL AND VOID! PLEASE DATE SIGN AND PROMPTLY RETURN IT TO THIS OFFICE.
I also agree to notify immediately, if I cease to represent the above mentioned patient. Law Firm:_______________________________________________________________________ Address:________________________________________________________________________ City:____________________________________State_____________Zip___________________ Phone #:________________________________ Fax #:__________________________________ Attorney Signature: _______________________________________Date: ____________ NOTE; ANY ALTERATION OF THIS LIEN MAKES IT NULL AND VOID! PLEASE DATE SIGN AND PROMPTLY RETURN IT TO THIS OFFICE.