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Mass Ave Chiropractic611 Massachusetts AveIndianapolis, IN 46204Phone 317-554-0748 Fax 724-863-1429Informed Consent To Chiropractic Examination, Diagnostic Procedures,Chiropractic Adjustments and Care, and Axial Decompression TreatmentPAGE 3I hereby request and consent to the performance of: physical examinations and evaluations and performance of anytests or X-rays required to be performed to diagnose my conditions, of chiropractic adjustments and other chiropracticprocedures, including various modes of physical therapy, of Axial Decompression, on me or on the patient namedbelow, for whom I am legally responsible by or under the supervision of the doctor of chiropractic named belowand/or other licensed doctors of chiropractic: who now or in the future treat me while employed by, working, orassociated with, or serving as back-up for the doctor of chiropractic named below, including those working at the clinicor office listed below or any other office or clinic.I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinicpersonnel, the nature and purpose of Axial Decompression, chiropractic adjustments and other procedures, Iunderstand that results are not guaranteed.I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risksto treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expectthe doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercisejudgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, isin my best interests.I have read, or had read to me, the above consent. I have also had an 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 oftreatment for my present conditionss and for any future conditions for which I seek treatment.Patient's Name and Date of B irth:To be completed by patient:To be completed by patient's representative, Ifnecessary, e.g., if patient is a minor or isphysically or mentally incapacitatedPrint Name of Patient's RepresentativeSignature of Patient/ Date:PRINT Name and DOB:Date:Dr. Joseph Kielur/ Date:Mass Ave Chiropractic, Inc.Signature of Patient' Representative andRelationship of Authorityof Patient's RepresentativeWitness to Patient's Signature/Date:SIGNATURENAME and DOB:DATE:
Indianapolis, IN 46204 Phone 317-554-0748 Fax 724-863-1429 PAGE 3 Informed Consent To Chiropractic Examination, Diagnostic Procedures, Chiropractic Adjustments and Care, and Axial Decompression Treatment I hereby request and consent to the performance of: physical examinations and evaluations and performance of any .
