The Chiropractic Office of....
Dr. Jill Buschmann

Dr. Jill Buschmann, Chiropractor
120 East Main Street (Route 110)
Merrimac, MA 01860



Patient Authorization for appointment reminders and scheduling related matters and for contact regarding chiropractic care, related health services and/or related health products

It is our desire for our staff to use your name, address and/or telephone number for the purpose of contacting you to remind you about scheduled appointments, re-evaluations or other appointments related issues and to advise you about health related meetings, workshops and products.

The use of this information is intended to make your experience with our office more efficient and productive. If you choose not to authorize this information use, your decision will have no adverse effect on your care form Dr. Jill or on your relationship with our staff.

Your signature indicates your authorization of this activity.








Name (printed)





This authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed.