I request and consent to Dr. Jeffrey Cassis, DC for Chiropractic / Alternative care consisting of a Consultation, History, Examination, Evaluation, Diagnostic Test, X-rays (if ordered), Adjustments, Chiropractic procedures, Physical Therapy and additional Holistic treatment services in regard to my care.
The doctor may refuse my case for treatment.
If the doctor believes that I may respond to additional service or care, he may recommend referral to a Specialist.
I authorize the release of any medical information the doctor deems necessary for my case.
I am requesting these services under the terms of private pay, meaning NO insurance is accepted or processed. I am responsible for all charges to me and I understand that I must cancel or reschedule appointments 24hrs before my scheduled time or be responsible for a missed visit fee.
I understand, no guarantee or assurance may be made to the result that may be obtained.
I understand and am informed that, as in the practice of medicine, in alternative care there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate all risks and complications based upon the facts then known to him during the course of the procedures and it is my responsibility to let him know any issues or complications that arise from my care.
I have read the above consent and had the opportunity to consult and ask questions about its content, and by initializing below I agree to the above. I intend this consent to cover the entire course of my treatment for my present and any future conditions for which I seek treatment.