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SW Room 509F HHH Building Washington DC 20201 Page 1 of 2 Patient initials -retaining page 1 of 2 JDD DC 5/2011 I have received a copy of Impact Chiropractic s Patient Privacy Notice. Patient or Authorized Person s Signature Doctor s Signature Date Completed Date Form Reviewed Patient s Name HR // Informed Consent REGARDING Chiropractic Adjustments Modalities and Therapeutic Procedures I have been advised that chiropractic care like all forms of health care holds certain risks. YOUR RIGHTS To...
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