Adult Patient Form

Chiropractic Care

Confidential Patient Information


Do you have difficulty with any of the following?

I have disclosed all the medical conditions that I am aware of. I release the therapist from all liability concerning any problems that may arise from the massage from any information knowingly omitted.

I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe and that nothing said in the course of the session should be construed as such.

It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the full scheduled appointment.

Kindly allow 24 hours cancellation notice for all appointments. A cancelled appointment that does not provide the required 24 hrs notice will result in a charge for the full fee of the massage booked. Our cancellation policy was created to best serve our patients and to create opportunities for new appointments.

To maintain a calming atmosphere, children are not permitted. For the safety of your children, we ask that they not accompany you to the appointment as they cannot be left unattended.