The following office procedures allow Cohasset Family Chiropractic to operate in an efficient manner and allow us to support our practice members/patients with their care. By signing below you are giving us the authorization to follow through with these procedures. Should you desire something not to be done, place a line through anything you refuse and initial.
We may need to contact you by telephone at home or at work regarding appointments and other matters related to care in this office.
We may need to leave a message with another person (e.g. spouse, co-worker) or on an answering machine/voice mail at home or at work regarding appointments and other matters related to care in this office.
We routinely have mailings (including email) from our office sent to you at your home or email address.
We acknowledge and thank everyone who refers to friends or family members to our office for chiropractic care.
We would like to directly thank the person who referred you and use your name.
You have the right to refuse any part of this authorization without affecting your care or the relationship with anyone at Cohasset Family Chiropractic.
This authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed.
Your signature indicates your authorization of these activities (unless crossed out and initialed). This notice is effective as of the date below and expires seven years from the date you last received services in this office.