I understand that I am financially responsible for all charges, whether covered by my health insurance plan or not. I authorize the Chiropodist to release all information necessary to secure the benefit of payments. I understand that fees for service are payable at the time of service and insurance reimbursement is my responsibility.
I hereby give consent for examination and treatment by the Chiropodist and/or anyone working in the clinic authorized by the Chiropodist and allow photographs of treatment areas for the purpose of monitoring.
I consent/allow the Chiropodist to send my Physician or health care professional a report regarding my foot exam and treatment plan.