Consent Please fill-out the form to the best of your ability and then “submit.” ***We will review all the information at your visit. *** Consent to Chiropractic Services Consent Full Name The above referenced person consent to the following (CHECK ALL THAT TO WHICH YOU GIVE CONSENT) 1. The performance upon myself of the following procedure(s): Chiropractic Adjustments, Tractioning (to restore normal curves), Posture Specific Exercises, and/or any other therapeutic procedures other than those stated above that HPC Physicians and/or assistants may consider necessary or advisable in the course of my health care. 2. The nature and purpose of the procedures, possible alternatives, risks involved, the possible consequences, and the possibility of complications have been explained to my satisfaction by HPC Physicians and/or assistants. 3. I acknowledge that no guarantee or assurance of the results that may be obtained from the procedures has been given by HPC Physicians and/or assistants. Full Name Date Signature (Leave Blank) If you are human, leave this field blank. Submit Δ Share this:TwitterFacebookLike this:Like Loading...
