Cornerstone Chiropractic

Receipt / Statement Request

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1Your Information

2Income Tax Information

First Name*

Last Name*

Email*

Phone*

Please select the option that applies to you*

I would like a printed receipt/statement

I would like my receipt/statement to be emailed

Please select the form of statement that you would like to receive

Insurance Receipt (all dates and payments listed)

Income Tax Receipt

Please indicate the date range of the statement you're requesting

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from

to

to

For what year would you like your income tax receipt?*

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