I herby authorize the doctor and whomever they may designate as the assistants to administer: treatment, physical examination, X-Ray studies, laboratory procedures, chiropractic care or any clinic service he/she deems necessary in my case. I further authorize him/her to disclose all or any part of my (patient’s) record to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member or employer of the patient for all or any of the clinic’s charge, including, and not limited to: hospitals, medical service companies, insurance companies, worker compensation carriers, welfare funds, or the patients employer.