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      Signatures

      I understand that the office of Dr. Jay Leidy does not file insurance claims. I understand and agree that health/accident
      insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services
      rendered to me and charged are my personal responsibility and are due at time of service.

      Have you ever suffered from any of the following?

      Please use the following letters to indicate TYPE and
      LOCATION of the symptoms you currently are
      experiencing.

      A= Acne O = Other
      B=Burning P=Pins & Needles
      N=Numbness S=Stabbing
      © Copyright 2005 ChiroMatrix
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      Leidy Chiropractic, LLC

      1595 Skylyn Drive – Unit B

      Spartanburg, SC 29307

      AUTHORIZATION FOR EXAMINATION, REMEDY AND PAYMENT



      I understand that Dr. Jay Leidy may suggest a program of nutritional supplementation as part of the healing process. Analysis of body imbalances are based on muscle testing. It in no way enters into diagnosis of diseases or conditions. These findings only imply that the condition named is an imbalance and not a pathological disease process. Copyright 1990 by Theodore A. Baroody





      ASSIGNMENT AND AUTHORIZATION

      TO: Your Holistic Healthcare / Leidy Chiropractic
      1595 Skylyn Drive, Unit B
      Spartanburg, SC 29307

      In consideration of your undertaking to evaluate me, I agree to the following:

      1. I hereby attest to the accuracy of my medical and/or accident history and further certify thatI present myself to Dr. Jay Leidy for evaluation and/or remedy of a health-related condition and for no other purpose. I clearly understand that I am totally responsible for payment.

      2. I understand that the Office of Dr. Jay Leidy does not file insurance claims. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility and are due at time of service.