Authorization

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My signature authorizes All-Star Chiropractic, Inc. and Dr. David J. Doperak to utilize my digital x-rays, digital posture pictures, and pictures related to Chiropractic BioPhysics treatment protocols - specifically, Mirror Image® (Opposite Position) Postural Adjustments, Mirror Image® Spinal/Postural Exercise, and Mirror-Image® Traction in print and electronic media.

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Authorization

  1. 1. -AUTHORIZATION- Today’s Date: Print Name: Signature: My signature authorizes All-Star Chiropractic, Inc. and Dr. David J. Doperak to utilize my digital x -rays, digital posture pictures, and pictures related to Chiropractic BioPhysics treatment protocols - specifically, Mirror Image® (Opposite Position) Postural Adjustments, Mirror Image® Spinal/ Postural Exercise, and Mirror-Image® Traction in print and electronic media. Thank You! All-Star Chiropractic, Inc. 4859 N 20th St, PHX AZ 85016 All-Star Chiropractic Website Dr. David J. Doperak ♦ Doctor of Chiropractic ♦ All-Star Chiropractic,Inc.

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