Your authorization is requested for purposes of delivering your care in an open adjusting or open door adjusting environment as described in the office's privacy notice.
In the course of your care either of these environments may cause details of your condition and care to be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details ofyour care will be addressed and considered as confidential by other patients.
This authorization has been requested by Darren J. Avise, Avise Chiropractic, PLLC. The purpose of this authorization is to allow for phone/reminders at home/ work and your signature on a sign in sheet.
We are requesting your authorization in these regards to assure that you are fully informed and in agreement with the method and circumstances in which we deliver chiropractic care. Your care will not be conditioned on your agreement to this authorization. You have the right to not sign this authorization and you also have the right to revoke this authorization at some time in the future please advise us accordingly in writing.
If you agree to this authorization copy will be maintained by this office and a copy will be provided to you.
Thank you for your cooperation and understanding.