Chiropractic Clinic Policies and Procedures Acknowledgment Form
Please review and complete this form to acknowledge your understanding of our clinic's policies and procedures.
Full Name
*
First Name
Last Name
Relationship to Patient
*
Self
Parent/Guardian
Other
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Communication Method
*
Text Message
Phone Call
Email
Cancellation & No-Show Policy Acknowledgment
*
I have read and understand the clinic’s cancellation and no-show policy.
Financial Responsibility Acknowledgment
*
I acknowledge that I am responsible for all charges not covered by my insurance.
Consent for Chiropractic Care and Procedures
*
I consent to receive chiropractic care and procedures as explained by the clinic.
Privacy & Communication Preferences
I authorize the clinic to leave voicemail regarding appointments.
I authorize the clinic to send appointment reminders via text/email.
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Acknowledgment
Submit Acknowledgment
Should be Empty: