• Consent to Release Records

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  • hereby authorize the named parties to release any medical information including the diagnosis, medical records, and X-Ray imaging rendered during my treatment.

     

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  • Release to:

    DeYoung Chiropractic

    400 68th ST SW

    Grand Rapids, MI 49548

    P: 616-281-2500

    F: 616-281-2502

    E: info@DeYoungChiropractic.com

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