Consent to Clinic Services

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  • I. ASSIGNMENT AND RELEASE

  • and assign directly Mikhail Family Chiropractic & Sports Rehabilitation Center, LLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.
  • II. CONSENT TO CHIROPRACTIC SERVICES

    I hereby request and consent to chiropractic manipulations, soft tissue treatments, rehabilitation, acupuncture, and other procedures including various modes of physiological therapy, and/or diagnostic tests by Mikhail Family Chiropractic & Sports Rehabilitation Center, LLC and staff who now or in the future treat me while employed by this office. I have had an opportunity to discuss with the doctor named above and/or with other clinic personnel the nature and purpose of the treatment indicated. I understand that no health care facility can guarantee results. Our clinic can’t guarantee results, but we have a high success rate with the conditions we treat because of our integrated approach and because of implementing the most up to date and research supported clinical practices. I am informed that, 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 be able to anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgment during the course of any procedure which the doctor feels at the time is in my best interest. I have read, or have had read to me the full above consent and have also had an opportunity to ask questions about its content and by signing below I agree to the above terms and procedures. I intend this consent to cover any treatment for my present condition and for any future conditions for which I seek treatment by this clinic and/or employed staff.
  • III. APPOINTMENT CHANGE NOTIFICATION

    I have read and understand the appointment change notification policy and understand that if I change my appointment time with less than 24 hours notification, I will subsequently be charged a $20.00 fee.
  • IV. CONSENT TO TREATMENT OF A MINOR CHILD

    I authorize the licensed doctor to administer care as deemed necessary to my:
  • Electronic Signature

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