ANTHON CHIROPRACTIC CARE
DR. GEORGE ANTHON, JR.
105 SOUTH CHERRY STREET
HAMMOND, LOUISIANA 70403
985-542-1640
How were you referred to our clinic?
 Yellow Pages Mail Newspaper Friend Attorney
     
  
     
     
Sex - Male   Female    |    Marital Status - M   S   D   W   |  
  
  
  
     
Are you covered by private medical insurance? Yes   No  
        
     
        
     
  
 
At this time I am not knowingly pregnant -
I AUTHORIZE DR. GEORGE ANTHON, JR. TO PERFORM THE NECESSARY TREATMENTS TO TREAT MY CONDITION, RELEASE MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS OR ATTORNEY'S, AND I WILL BE DIRECTLY RESPONSIBLE FOR ANY PAYMENT OF MY ACCOUNT NOT COVERED BY MY INSURANCE.