Patient’s Name__________________________________________________Date_________________

 

Liability Release Chiropractic Care Agreement

Acceptance of you as a patient of this facility should not be construed as a guarantee of results in our dealing with your particular health concerns. We shall, however, make every effort, within our particular talents and abilities, to allay the condition(s) for which you have consulted us. While high percentages of human ailments respond favorably to chiropractic care, not all do, and in some cases referral to specialist in other disciplines may be necessary.  Risk of spinal manipulation is minimal but does exist. However, in our experience we have no untoward incidents from our adjustment of spinal segments. Efforts to prevent such incident in this office begin with a thorough spinal examination.

 

X______________________________________________ date ________________________

 Signature

 

Liability Release Nutritional Consultation   Notice of Understanding and Agreement

I fully understand that the nutrition consultant that I am seeing is not a medical doctor and I am not consulting for medical, diagnostic or treatment procedures.  The services performed by the nutrition consultant are at all times restricted to helping me gain a better understanding of my degree of health (not disease), so I will have a greater self-awareness and be able to use a self care program for daily living.  I understand that as a nutrition consultant the recommendations, discussion, sale of food, nutrition, nutritional supplements, vitamins or minerals, food grade herbs or other nutrients as foods for special dietary use only pertain to the whole body concept of nutrition, and does not relate in the context of any specific ailment or condition.  The appointments do not involve the diagnosing, prognostication, treating or prescribing of medicines or the treatment of disease, or any act which will constitute the practice of medicine in this state, for which a license is required.


X______________________________________________ date ________________________

 Signature

 

Liability Release Physical Therapy Agreement

I understand I am engaging Toensing Family Chiropractic (TFC) for the purpose of providing me with physical therapy, rehabilitative, and strength training instruction.  I hereby release TFC their owners, agents, employees, and contractors, including any facilities where instruction takes place, from any responsibility, and I agree to hold them harmless from any and all liability, claims, damages, actions, and causes of action whatsoever, for loss, damages, or injury to person or property, irrespective of how arising and however caused.


X______________________________________________ date ________________________

 Signature


I hereby authorize the hereon identified provider to release information acquired in the course of my examination or treatment as we are legally obligated and certify that the above information is correct and complete.

 

X______________________________________________ date ________________________

Signature