A 15-minute therapy

that slowly & gently separates the vertebrae of the neck.
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Chiropractic Patient Information

Integated Spinal Solutions, Terms of Acceptance

Patient Will Truthfully and Fully Disclose Health Status and History

I hereby state that all information that I hereby give Integrated Spinal Solutions, pc and/or it’s staff will be complete and truthful. I will not misrepresent my presence, nature, severity or cause of my injuries. I further state that I will fully disclose my health history and authorize the release of all past medical records to Integrated Spinal Solutions, pc. I present myself for health reasons only and it is not my intent to mislead, defraud or coerce this office or any third party or misrepresent myself in any manner.

Patient Consents to Care and Accepts Responsibility

I consent to recommendations and care by the Doctor(s) of Integrated Spinal Solutions, pc for myself (or my children if minors) including, but not limited to examinations, x-rays, chiropractic adjustments, rehabilitative and physical therapy. I understand that my care will be individualized to me and therefore may not be comparable to standards or guidelines used or required by insurance companies, professional associates, and/or consensus groups. I understand that my treatment will comply with the inherent risks. These risks, though rare, could occur ranging from minor aggravation of current condition to serious conditions such as cerebral vascular accident or death. I am signing this consent after having been fully informed to my satisfaction by the Doctor(s) of Integrated Spinal Solutions, pc and/or his staff of the risks and benefits of the care and the risks and benefits of not having the recommended treatment. I have been informed and fully understand that there are no guarantees of treatment success. By my presence and continuation of appointments, I consent and elect to care provided by Doctor(s) of Integrated Spinal Solutions, pc and/or his staff.

I have read, understand and agree to the provisions and terms of acceptance. This agreement shall become effective upon signing and be irrevocable for the full extent of my treatment by the doctor.

Patient Name (please print):
Patient Signature:        Date:

Integrated Spinal Solutions Patient Intake Form

Physical Therapy
Our physical therapist has vast experience in treating both the MPS and FMS patient with acupressure, dry needling, manual techniques, exercise, and modalities. ...read more
Massage Therapy
I’m certified in thirteen different massage modalities, however I specialize in structural, deep tissue massage, sports massage and pregnancy massage ...read more

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