ORTEGA CHIROPRACTIC CLINIC
Phone:(904)425-4545
Fax:(904)425-4548
Patient's Name
19/09/2025
Date
Rx:
Free Initial Chiropractic Consultation and Examination.........
($225 value)
Ortega Chiropractic Staff
Doctor/Staff/Signature
14 days from today
Expiration Date
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.
ORTEGA CHIROPRACTIC CLINIC
Phone:(904)425-4545
Fax:(904)425-4548
Patient's Name
Date
Rx:
Free Initial Chiropractic Consultation and Examination.........
($225 value)
Ortega Chiropractic Staff
Doctor/Staff/Signature
14 days from today
Expiration Date
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.
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