Purpose of Visit

HEALTH CONDITIONS

Please indicate if you currently have or have a history of any of the following injuries or illnesses.

FAMILY HEALTH HISTORY

I authorize and agree to allow the doctor(s)and/or physical therapist to work with my spine through the useofspinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal biomechanical and neurological function. I acknowledge and understand that even though negative results are rarely experienced, as with any form of treatment they are possible. Some of the potential risks may include but are not limited to: fractures, worsening of symptoms, muscle injury, joint irritation/dislocation. I recognize it is my responsibility to inform of the doctor of any and all conditions that may affect my care.

Although no significant data shows a correlation between chiropractic adjustments and the cause of stroke, I understand that there is concern in certain situations and if I have questions I agree to consult with my doctor. In the uncommon case that negative results from treatment occur at any time, I will notify the doctor immediately so that proper treatment can be administered and the result noted for future reference.

It is with full understanding and acknowledgment that I authorize and agree to the recommended course of treatment for conditions related to my spine and joints as prescribed by my doctor in this office.

I understand that I am responsible for all fees incurred for the services provided, and agree toensure full payment of allcharges.

The Doctor and/or physical therapist will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions diagnosed at this clinic.

I also clearly understand that if I do not follow the doctors and/or physical therapist specific recommendations at this clinic that I will not receive the full benefit from these programs, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time.

I authorize the assignment of all insurance benefits be directed to the doctor and/or chiropractic office(s)for all services rendered.

I do hereby give my consent to allow this office and its representatives, as deemed by the examining physician to take radiographs of my spine and/or extremities.

Please only fill out the following information if we have not received a copy of your insurance card

IN CASE OF EMERGENCY