Chiropractic Wellness Intake

I consent to chiropractic examination and clinically indicated care, which may include spinal or extremity manipulation/mobilization, manual therapy, therapeutic exercise, neuromuscular re-education, traction, physiotherapeutic modalities and patient education. Common temporary effects may include soreness, stiffness, fatigue or temporary symptom aggravation. Less common risks include sprain/strain, fracture in susceptible individuals, disc or nerve aggravation and other injury. Cervical manipulation has been associated with rare serious neurologic or vascular events. I may ask questions, decline any procedure or withdraw consent at any time.

I understand wellness care may support mobility, function, comfort and healthy habits but does not guarantee prevention, cure or a specific outcome. Chiropractic care does not replace emergency care, primary medical care or specialist care when indicated. I will disclose important changes in symptoms, medications, pregnancy status and health history.

I understand insurance verification is not a guarantee of payment and that some preventive or wellness services may not be covered. I accept responsibility for lawful charges disclosed to me and understand recommended care is based on clinical need, not a promise of insurance coverage.

I acknowledge that I have been offered access to the clinic Notice of Privacy Practices. I certify that the health, medication and contact information supplied is accurate and complete to the best of my knowledge and agree to notify the clinic of material changes.