By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
Abundant Health Physical Medicine - Informed Consent: REGARDING: Medical Services, Chiropractic Adjustments, Modalities, Functional Medicine, Regenerative Medicine, Extracorporeral Shockwave Therapy, Aesthetic Procedures and Therapeutic Procedures: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related in one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments. Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Abundant Health Physical Medicine 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 have reviewed and accepted informed consent.
I, (Type Full Name)* herby authorize Abundant Health Physical Medicine to discuss with and/or release information to the following people concerning my appointments, insurance, billing, and health treatment rendered.
I understand I may terminate this consent at any time by giving written notice to Abundant Health Physical Medicine. Any changes to this form will require a new consent to be completed, signed and dated.
I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.