Female Patient X-Ray Pregnancy Verification Form


I, _________________________________, a patient of Wilmington Family Chiropractic, certify that to the best
of my knowledge that I am not pregnant. By my signature below, I authorize Wilmington Family Chiropractic
and Dr. Jensen to take all appropriate diagnostic x-rays. If there is even a remote chance of pregnancy, I will
notify Dr. Jensen immediately.
Signed: __________________________________________________ Date: __________________________
Doctor’s Signature: __________________________________________Date: __________________________
I understand that all records established by this office are the sole property of Dr. Jensen. Copies, however, will
be made upon 72 hours written notice to the doctor, and I understand and agree to pay all costs involved in their
I hereby give Wilmington Family Chiropractic and Dr. Jensen CONSENT TO TREAT me and/or my minor
child, and I understand that Wilmington Family Chiropractic requires personal payment for all services
rendered today.
I, the undersigned, hereby authorize Dr. Jensen (and whom he may designate his assistants) to administer any
examination and/or treatment as is necessary and to perform appropriate diagnostic and therapeutic procedures
as are considered necessary on the basis of findings during the course of said examination and/or treatment. I
also authorize the release of any information or records from this office to other past, present or future health
care professionals, facilities, attorneys or agencies for the purpose of continuity of my health care and for the
purpose of collection for services rendered.
I understand and agree that health and accident insurance policies are an arrangement between an insurance
carrier and myself. Furthermore, I understand that Wilmington Family Chiropractic will prepare any necessary
reports and forms to assist me in making collections from the insurance company and that any amount
authorized to be paid directly to Wilmington Family Chiropractic and Dr. Jensen will be credited to my account
on receipt. I also give Wilmington Family Chiropractic and Dr. Jensen limited power of attorney to endorse
checks received from my insurance company relating only for my treatment, to be credited to my account.
However, I clearly understand and agree that all services rendered to me and/or my minor child are charged
directly to me and that I am personally responsible for payment, regardless of my insurance coverage. I also
understand that if I suspend or terminate my care and treatment and/or if in the event that my insurance benefits
are terminated or exhausted, any fees for professional services rendered to me and/or my minor child will be
immediately due and payable.
I also certify that no guarantee has been made as to the results that may be obtained from any treatment given.
By signing below, I affirm that I have read the above and that it has been clearly explained to my as well by
Wilmington Family Chiropractic.
Patient or Guardian Signature
New patient form: x-ray permission


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