Family Health History Template (Page 2 of 8) in pdf

TERMS OF ACCEPTANCE

When a patient 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 understands both the objective and the

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

Adjustment: The adjustment is the specific application of forces to facilitate the body’s correction of

vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: The 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 subluxations. 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 another 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 major interference to the

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

I, ______________________________ have read and fully understand the above statements.

(print name)

All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my

complete satisfaction.

Therefore, I accept chiropractic care on this basis.

_________________________________

_____________________________

(signature)

(date)

Consent to evaluate and adjust a minor child

I, ________________________________ being the parent or legal guardian

of____________________________ have read and fully understand the above terms of acceptance and hereby grant

permission for my child to receive chiropractic care.

(Continued on Back)

Family Health History Template Page 2