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Cambridge ChiropracticPetrice Foxworthy, D.C.3939 Cambridge Road, Suite 100 • Cameron Park, CA 95682 |
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Informed Consent and Patient Payment AgreementI 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 by the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who are now, or may be employed in the future, treat me at the clinic or office listed below. I understand the results are not guaranteed. I understand an am informed that, as in the practice of medicine, in the practice of chiropractic, 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 anticipate and explain all risks and complications. 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 all factors then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had the opportunity to ask questions about its content; and, by signing below, I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Please keep in mind that your insurance is a contract between you and your insurance carrier. We are not responsible for erroneous information given to us by you or your insurance company. Therefore, if at any time your insurance carrier discontinues coverage or denies payment on your account, you will be responsible for all charges in this office. Cash patients are responsible for all charges in this office. If you have any questions regarding your insurance, please ask someone in our insurance department. We wish to thank you for choosing our office for your health care needs and we look forward to helping you in any way we can. |
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