701-365-0401 dwaale@gmail.com
417 Main Ave Suite 301 Fargo, ND 58103
  • I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that i am responsible for all costs of chiropractic care, regardless of insurance coverage.


    The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, patient communications, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health information we encourage you read the HIPAA NOTICE that is available to you at the front desk before signing this consent.


    The following person(s) have my permission to receive my personal health information:
  • HISTORY OF PRESENT AND PAST ILLNESS

  • Have you had or do you now have any of the following symptoms/conditions? Please Check Accordingly
  • INFORMED CONSENT

  • WAALE CHIROPRACTIC CLINIC PLLC | DR DAVID WAALE DC
    ADDRESS 417 Main Ave Suite 301 Fargo, ND 58103 PHONE 701-365-0401
  • I will use my hands or a mechanical instrument upon your body in such a way as to move your joints. This procedure is referred to as "Spinal Manipulation" or "Spinal Adjustment" As the joints in your spine are moved, you may experience a "pop" as part of the process.

    There are certain complications that can occur as a result of a spinal manipulation. These complations include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, fractures, strains and dislocations, Bernard-Horner's Syndrome (also known as oculosympathethetic palsy), costovertebral strains and separations. Rare complications include, but are not limited to stroke. The most common complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment.

    I am aware of these complications, and in order to minimize their occurrence i will take precautions. These precautions include, but are not limited to my taking of a detailed clinical history of you and examining you for any defect which would cause a complication. This examination may incluyde the use of x-rays. The use of x-ray equipment may pose a risk if you are pregnant. if you are pregnant, you should tell me when i take your clinical history.




  • ___________________________________________
    Signature



  • ___________________________________________
    Signature of parent / guardian (if a minor)