I hereby request and consent to the performance of chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by Dr. Angel Gaspar and/or anyone working in this office authorized by Dr. Angel Gaspar.

 

I have had an opportunity to discuss with Dr. Angel Gaspar, and/or with anyone working in this office authorized by Dr. Angel Gaspar the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

 

I understand and am informed that, as with the practice of medicine and all healthcare, chiropractic carries some risks to treatment, including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I consent to rely on the doctor’s best judgment, exercised during the course of treatment that is in my best interest, based upon the known facts.

 

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