New Client Registration

Consent to Treat Authorization: I hereby grant authorization for the Chiropractor of Premier Wellness and Chiropractic to render care in any place or location that treatment and services are rendered. I understand that a full history and examination is needed in order to treat injuries or conditions presented on initial date of service. I agree to notify the Chiropractor of all conditions and injuries that I am seeking to get treated at this point in time. I authorize the Chiropractor to document all treatments rendered on each date of service according to prescribed treatment plan. If any life-threatening issues arise, I will notify the Chiropractor of such events or entrust the Chiropractor to offer emergency care or transport me to an emergency center. I understand that I am responsible for payment of any and all services rendered to me by the Chiropractor of Premier Wellness and Chiropractic. By signing below, I agree to the above statement and would like to begin care:

Medical Questionnaire