Financial Disclosure Form

I hereby give my consent for Dr. Scott R. Underwood, D.C., and/or other licensed chiropractic or medical professionals employed by or practicing at Underwood Chiropractic PLLC, to perform chiropractic adjustments, Active Release Technique therapies, or other chiropractic or medical procedures on me. I have had the opportunity to discuss with Dr. Underwood or other staff members the nature and purpose of these treatments. I understand that neither chiropractic nor medicine is an exact science and that my care may involve judgments based on the facts known at the time; that it is unreasonable to expect the doctor to predict or explain all risks and complications; that an undesirable outcome does not necessarily mean there was an error; that no guarantees about results have been made or relied upon by me, and I trust the doctor to exercise their judgment during the procedure, based on the facts available at that moment, to act in my best interests. I have also been informed that, although the risk of complications from chiropractic services is very low, patients should be aware of possible complications, which have been alleged. These include, but are not limited to: fractures, disc injuries, strokes, dislocation, sprains, minor soreness, and issues related to physical abnormalities that may be unknown or difficult to detect. I have read or have had read to me the above consent. I have also had the opportunity to ask questions about its contents, and by signing below, I acknowledge my understanding of its terms.