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

To help us with total quality health care for our patients we would like to increase communication between our office and your medical doctor. If you would be interested in our new policy, please complete the authorization form, and we will periodically send an updated report to:

Medical Doctor: ________________________________________________________________________

Address: ______________________________________________________________________________

City/State: _____________________________________________________________________________

Signature of Patient: _____________________________________________________________________

Date: ___________________________ Witness: ___________________________________