I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination, and treatment.  I hereby assign, transfer, and set over to Care Today Clinic all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy.

I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization.

I understand that I am financially responsible for all charges whether or not they are covered by insurance.