I certify that I am the patient, or the legal guardian of the patient listed above. I have read and understand the information provided and certify it to be true and accurate to the best of my knowledge.

I consent to the collection and use of this information by this chiropractic office. I authorize this office and its staff to examine and treat my condition as the doctor sees fit. I authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement. I understand that all services rendered will be charged to me and that I am responsible for timely payment. I understand that health and accident insurance policies are an arrangement between an insurance carrier and myself, and that fees for professional services will become immediately due upon suspension or termination of care.

By providing my contact information, I authorize Community Chiropractic to use my name, the name of my care provider, and appointment information to contact me regarding pending appointments, missed appointments, overdue wellness visits, balances due, and other care-related communications via phone, text, or email. I understand that others with access to my devices or accounts may see these messages.