Page 8 – Master Signature Page (Sign here) ---



MASTER SIGNATURE PAGE



I confirm that I have read and signed all documents on pages 2 through
7 of this document package. I agree that the practitioner may select
applicable services based on my condition. I understand that each
follow-up visit requires a separate Intake & Follow-up Form (Page 9)





Patient name (print): ____________________

Patient signature: ____________________

Date: ____________________



Practitioner signature: ______________________

Date: _____________________