Consent to Examination

I, (Name), consent to an examination on (Month) (Day), (Year), as deemed necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.


Please fill out the Contact Form below by providing us with your Name, Email and Phone Number.

If you agree with the above statement, please Copy and Paste the above statement in the Message box, with your Name and today's date including the Month, Day and Year in the according layout.

Once the form is complete, please press Send.