Wayne A. Comeau, D.C. DACBOH

Parry N. Comeau, P.T., D.C.

194 North Street

Danvers, MA 01923-1219

978-774-5600 Fax – 978-774-5601

Date: __________________________

The following is the office policy regarding "supplies" such as, but not limited to;

Theragesic Analgesic Balm

Nutritional Suppliments

Ice/Hot Packs

Orthotic Devices

As your insurance policy/ Managed Care Company does not cover these supplies you are required to pay for same as they are dispensed unless other arrangements have been made in advance.

I, the undersigned, have read and understand the above.

Signature:______________________________________________________________________________