I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x - rays, on me (or on the patient named below, for whom I am legally responsible) by Dr. Son Nguyen, DC and/or other licensed Doctors of C hiropractic who now or in the future treat me while employed by, working, or associated with or serving as back - up for Dr. Son Nguyen, DC including those working at the clinic or office listed below or any other office or clinic.
I will have/had an opport unity to discuss with Dr. Son Nguyen, DC and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures.
I understand and am informed that, as in the practice of medicine, in the practice of chiropract ic there are some risks to treatment including, but not limited to, fractures, disk injuries, strokes, dislocations, and sprains. I do not expect the do ctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I understand that I have the right to seek other healthcare professionals for my condition and treatment.