I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this chiropractic office will be credited to my account on receipt. However, I clearly understand that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. Original X-rays will always remain the property of this office. A fee will be charged for any copies of X-rays that are needed. A 1% interest per month plus collection fees and attorney fees will be added to any account 90 days past due. There will be a $10 fee charged for missing three appointments without any notice.

I consent to any physical examination, X-ray study, laboratory procedures, chiropractic or adjunctive therapy, or clinic service that is ordered under the general and specific instructions of the doctor(s). I also understand that the doctor will not be able to adjust my spine on the first visit.

I certify that the above information is correct to the best of my knowledge.

I will pay for services rendered on that day unless other arrangements are made prior to the examination.