CONSENT FOR TREATMENT/TERMS OF ACCEPTANCE
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by Dr. Ray L. Nannis and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for Dr. Ray L. Nannis, and or Optimum Wellness Solutions including those working at the clinic or office located at 1750 N. Collins Blvd. Suite 101-B Richardson, Texas, or any other clinic, whether signatories to this form or not.
I understand and am informed that, as in the practice of medicine, the practice of chiropractic there are some risks to treatment. I do not expect the doctor to be able to anticipate and explain all 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 interests.
When a patient seeks chiropractic health care and is accepted as a patient for such care, it is essential for both the patient and the doctor to be working towards the same objective.
Chiropractic has only one goal: The removal of interference from normal healing. It is important that each patient understand both the objective and the method that will be used to attain it.
This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustment of the spine.
Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others.
OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our method is specific adjusting to correct vertebral subluxations, nutritional and lifestyle advice, detoxification.
I understand that all records and x-rays taken in this office are the property of Optimum Wellness Solutions.
I have read and fully understand the above statements. All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.