I hereby authorize payment to be made to Connection Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further, acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Connection Chiropractic for all services I receive at this office. I authorize Connection Chiropractic to release and/or request records to or from other providers as may be necessary.
I herby release Connection Chiropractic of liability from complications that may arise from receiving any x-rays studies. I understand the inherent risk associated with exposure to x-rays. I understand the need for x-rays to properly diagnose and/or treat my condition.
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Females ONLY
I herby certify to the best of my knowledge that I am not pregnant and release Connection Chiropractic of liability for any complication that may arise from receiving any x-rays studies. By my signature below, I am acknowledging that I understand there are potentially hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray exam the doctor has deemed necessary in my case.
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I being parent or legal guardian of hereby consent to the performance of diagnostic testing of this minor at Connection Chiropractic by Dr. Lavergne or any legal agent of this clinic.
