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Parent/Guardian Signature Date // MCCORMACK CHIROPRACTIC OFFICE S.C. 519 Shepherds Drive West Bend 53090 262 -306-9775 MINOR S FORM 07/2013. Upon their request. I hereby authorize and direct payment of any medical/chiropractic expense benefits allowable to the doctor as payment toward the total charges for professional services rendered. This payment will not exceed my indebtedness to the assignee. I agree that a photocopy of this agreement shall serve as the original. I acknowledge I have...
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