THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.

Expiration Date

Doctor/Staff/Signature

($225 value)

Rx:

Fax:(904)425-4548

ORTEGA CHIROPRACTIC CLINIC

5367 Ortega Boulevard
Jacksonville. FL 32210
www.OrtegaChiropractic.com

Patient's Name

Date

14 days from today

Ortega Chiropractic Staff

Free Initial Chiropractic Consultation and Examination.........

Phone:(904)425-4545