New Patient Form – Hallandale

I authorize release of any information necessary to process my insurance claims only. I also assign and request direct payment to my physician if I utilize Medicare or personal injury protection insurance.

I hereby notify all concerned that I neither suspect nor know positively at this time that I may be pregnant. I release this clinic from any and all damages arising from any and all procedure of diagnostic x-ray or treatment with reference to the possibility of pregnancy.

I am the Legal Guardian and hereby authorize Furshman & Davis Family chirorpactic to administer care, deemed necessary.