Informed Consent to Chiropractic Care
Coldwater Chiropractic & Wellness Center
Dr. Nicole L. Hatt, BS, DC
Dr. Austin Collar, BS, DC
Dena Warfield-Testa, LMT
Julie Shepperd, LMT
I hereby request and consent to the performance of chiropractic manipulation or adjustments and other chiropractic procedures, including various modes of physical therapy or physical medicine procedures, nutritional counseling, supplement recommendations, massage therapy and diagnostic x-rays, on me (or on the patient named below for who I am legally responsible) by the doctor or clinician named above and/or other licensed doctors of chiropractic and clinicians who now or in the future treat me while employed by, working or associated with or serving as backup for the doctor of chiropractic named above.
I have had an opportunity to discuss with my doctor and/or with other office or clinic personnel the nature and purpose of chiropractic manipulations or adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all possible 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, is in my best interest.
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 form to cover the entire course of treatment for my present condition.