Name *

First Name

Last Name

Phone

(###)

###

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Consent to assessment, chiropractic adjustment, and filming. *

By checking this box you consent to the nature of the quick assessment, including the clinical reason(s) for assessment of the areas discussed, the potential risks of the assessment and chiropractic adjustment, the potential side effects of the assessment and adjustment. Consent is voluntary. I can withdraw my consent at any time during the assessment or adjustment, but I must speak up. I also consent to being filmed during the assessment or adjustment for social media purposes.