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New Patient OPQRST

Mailing Address

Current Complaints

Nature of Injury

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

CHIROPRACTIC INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.

I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and is in my best interest.

I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxation's and release muscle spasms, allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health Modalities results are not guaranteed and there is no promise to cure.

I further understand that there are treatment options available for my condition other than chiropractic procedures and that discussion has been made available to me. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

OC Chiro utilizes your cell phone number as your patient ID and as a primary point of contact for identifying you in our system. It will be utilized to transmit your medical records and general patient information to you.Your cell phone is your source of communication between you, our office and your doctor(s).OC Chiro will use your cell number to keep you updated on changes to our office including, but not limited to, special opportunities to schedule an appointment as well as modification to hours and availability for treatment.

Consent To Treat A Minor- Please fill out if you are a parent/guardian bringing someone in under the age of 18 yrs old for treatment. We cannot treat someone under 18 yrs old without this consent being filled out.

I/We the undersigned parents(s) and or guardian(s) of the person/patient whose name is listed above (See New Patient OPQRST area above for name) a minor, do hereby authorize this office and its doctor(s) to administer Chiropractic care to my child, as they deem necessary.

Please check the I authorize treatment box below if you agree with the terms of the Consent to treat a minor form.