Release and Indemnification
I hereby authorize St. John - Clark Pain Treatment Center to provide any and all information, copies, or records to any clinic, physician, lawyer, insurance company, or workman's compensation fund as deemed necessary. A copy of this authorization shall be considered as valid as the original.
I hereby authorize any physician to release any and all information and copies of all records to St. John - Clark Pain Treatment Center as deemed necessary for treatment. A copy of this authorization shall be considered as valid as the original.
I give permission that photographs and video footage may be taken of me or my X-rays, CAT, or MRI scans during the course of treatment at St. John - Clark Pain Treatment Center. These photographs are strictly to be used for treatment planning, or education for other healthcare practitioners and will not be displayed anywhere else without my written permission.
24 Hour Cancellation Policy
I understand that there is a 24 hour cancellation policy for scheduled appointments. Cancellation of a scheduled appointment must be made by calling St. John - Clark Pain Treatment Center. Failure to cancel without the minimum notice will result in the full charge for the cancelled or missed appointment. Cancellation for Mondays and the day after holidays must be made on the prior business day during normal business hours. Payment for the entire amount of the scheduled appointment will be expected regardless of the patient's arrival time.