I authorize and direct Dr. Sayers to perform upon me injections, draw blood and/or any other procedure/treatment they may determine advisable for my well being in their office. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the outcome of the procedures and/or treatment.
ASSIGNMENT AND RELEASE:
I authorize release of any medical information necessary to process an insurance claim. I agree to the responsible for any co-payments and/or services not covered by my insurance. I authorize payment of medical benefits to the physician or supplier of services.
NO SHOW POLICY:
No shows and same day cancellations are subject to a $50 charge.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.