Confidential Patient Information

Current Health

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse co-issued remittances for the conveyance of credit to my account. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. It is my understanding that my credit may be checked if ChiroWerx, PLLC extends credit to me and I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable unless prior arrangements are made. I hereby authorize the doctors at ChiroWerx, PLLC and whomever they may designate as assistants, to administer treatment as they so deem necessary and I also authorize the release of any information acquired in the course of my examination and treatment. I certify that the above information is true and correct.

PAST Medical History: Have you EVER had any of the following?

FAMILY Medical History

SOCIAL & OCCUPATIONAL History

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended integrative and complementary procedure to be used so that you make an informed decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure. NOTICE: Refusal to consent to the integrative and complementary procedure should not affect your right to future care or treatment. I (We) voluntarily request Dr. Dunning as my physician, and such associates, technical assistants, and other health care providers as they may deem necessary, to treat my condition, which has been explained to me as: spinal/extremity muscle injury or condition, ligamentous or vertebral disc injury, “pinched nerve”, vertebral or pelvic subluxation and/or extremity subluxation. I (We) understand that the following integrative and complementary procedure(s) is planned for me and I (We) voluntarily consent and authorize these procedures: spinal and/or extremity manipulation, manual muscle therapies, physical therapy modalities also known as ultrasound, electrical muscle stimulation, heat/ice, and spinal intersegmental traction. I (We) understand that no warranty or guarantee has been made to me as to the result of care. I (We) realize that just as there may be risks and hazards in continuing my present condition without conventional medical treatment, there are also risks and hazards related to the performance of the integrative and complementary treatment, alternative forms of treatment, risks of treatment, risks of non-treatment, procedures to be used, and the risks and hazards involved, and I (We) believe that I (We) have sufficient information to give this informed consent. I (We) certify this form has been fully explained to me, that I (We) have read it or have had it read to me and that I (We) understand its contents.