I First Name* Last Name* , hereby authorize the named parties to release any medical information including the diagnosis, medical records, and X-Ray imaging rendered during my treatment.
Release to:
DeYoung Chiropractic
400 68th ST SW
Grand Rapids, MI 49548
P: 616-281-2500
F: 616-281-2502
E: Xrays@DeYoungChiropractic.com