I agree to have Dr. Anthony Blasco and staff examine me or my dependent for the purpose of supporting my health and wellness.

 

I understand that UB Well Center, et al., cannot diagnose any disease or condition.  I also understand that any chiropractic care will be performed to reduce any subluxation (misalignment) of a joint.

 

I also agree that I am responsible for payment at the time of service.  I give my permission to The Practice to use my confidential health history for documentation purposes, to assess my health or that of my dependent and to obtain payment.