Notice of Privacy Practices: By signing below you acknowledge receipt of this practice's Notice of Privacy Practices and consent to the use and disclosure of your protected health information as described therein.

Informed Consent for Chiropractic Care: I voluntarily consent to chiropractic evaluation and treatment. I understand the nature, benefits, and risks of chiropractic care including but not limited to spinal manipulation, and that no guarantee of results has been made.

Accuracy Attestation: I attest that the information I have provided in this check-in is true, accurate, and complete to the best of my knowledge.

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Clinician Attestation: I attest that I personally performed or directly supervised all services rendered for this patient on this date. The documentation accurately reflects the services provided and my clinical findings and judgment. All services were medically necessary.

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