Informed Consent
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke-which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.
Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Covington Family Chiropractic LLC have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
I hereby authorize payment to be made directly to Covington Family Chiropractic LLC, for all benefits which may be payable under a healthcare plan or from any other collateral resources. I authorize utilization of this application, or copies thereof, for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Covington Family Chiropractic LLC for any and all services I receive at this office.