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We Create Healthy Families
I hereby request and authorize the providers at Dr. Ashley Family Chiropractic to administer care as
they deem necessary to my dependent minor child. This authorization also extends to include
diagnostic imaging, laboratory and other testing at the doctor’s discretion. I understand and agree
that health and accident insurance policies are an arrangement between an insurance carrier and
myself. I understand and agree that all services rendered to my child are charged directly to me and
that I am personally responsible for payment at the time services are rendered.
As of today’s date, I have the legal right to select and authorize health care service for the minor
child named above.
If applicable, under the terms and conditions of my divorce, separation, or other legal
authorization, the consent of a spouse, former spouse, or other parent is not required. If my
authority to so select and authorize this care should be revoked or modified in any way, I will
immediately notify this office.
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Not sure what to think about Chiro Care for Kids? Dive into research here.