TERMS OF ACCEPTANCE
I consent for Dr. Siegfried to consult with, examine and treat me if I agree to treat.
In seeking chiropractic health care and upon acceptance as a patient at this clinic for such care, it is essential for us both to be working towards that same objective.
Chiropractic health care 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.
Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or symptoms. This is the World Health Organization definition of health.
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 nervous system to function at its optimal potential.
Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation, which caused reduction in the nervous system function.
Spinal Decompression: Spinal decompression provides a non-drug, non-surgical treatment based on scientific principles to help reduce or eliminate herniated, degenerated, and bulging discs in the lower back and neck.
Bilateral Nasal Specific: Adjustment of the bones of the head with the intention of restoring normal movement and function.
Whole Food Concentrates: Products that contain whole foods high in certain vitamins and minerals necessary for the body to function at an optimal level.
I do not offer to diagnose or treat any disease or condition other than vertebral
subluxation. However, if during the course of a chiropractic examination, I encounter unusual findings, I will advise you. If you desire advice, diagnosis or treatment for those findings, we will give you recommendations for care.
I do not offer advice regarding treatment prescribed by others. My only practice objective is to eliminate a major interference to the nervous system. Our method is specific adjusting to correct vertebral subluxation and therapy to facilitate those adjustments.
If I choose not to follow all recommendations I therefore may not get the desired results.
I have read and fully understand the above statements. All questions regarding the doctor’s objectives 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.
Pregnancy Release:
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
_______________________________ ________________________
Signature Date