Pediatric History Form (Page 3 of 5) in pdf

Ferguson Family Chiropractic's TERMS OF ACCEPTANCE

When a person seeks chiropractic health care and we accept a patient for such care, it is essential for both

to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the

method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral

subluxation. Our chiropractic method of correction is specific adjustment of the spine.

Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease or

infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes

alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening

of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if

during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings,

we will advise you. If you desire advice,diagnosis, or treatment for those findings, we will recommend that

you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding

treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to

the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral

subluxations.

CONSENT TO CARE

I do hereby authorize the doctors of Ferguson Family Chiropractic to administer such care that is necessary

for my particular case. This care may include consultation, examination, adjustments, or any other

procedure which is advisable and necessary for my health care.

l further understand that a fee for services rendered will be charged and that l am responsible for this fee

whether results are obtained or not.

I also understand any sum of money paid under assignment by any insurance shall be credited to my

account, and l shall be personally liable for any and all of the unpaid balance to the doctor.

I ________________________, have read, understand, and hereby request chiropractic care based on the

terms of acceptance and the consent to care.

Signature: _____________________________________________

Date: _______________________

signature of parent or guardian if minor

Pediatric History Form Page 3