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  • New Chiropractic Intake Form

    New Chiropractic Intake Form

    Connecting the Disconnected Since 2008
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  • By signing below:

    • I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge.
    • I consent to the collection and use of the above information to this office of chiropractic.
    • I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctors to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me.
    • I understand and agree that all services rendered to me will be charged to me, and I'm responsible for a timely payment of such services.
    • I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
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