I give permission to Lillington Family Chiropractic, P.A. to discuss the following medical and billing information about me

1. Scheduling/appointment information

2. Medical information including: my history, symptoms, diagnosis, medications, and treatment plan.

3. Examination results.

4. Billing and payment information

* I understand that I may cancel this permission at any time, but that cancelling it will not affect any information that has already been released. I understand that I do not have to sign this form, and that I should only sign it if I want my medical provider or my clinic to share my information with someone.