Alton Chiropractic Waiver and Consent for Treatment

Waiver, Consent for Treatment, and Release of Liability

I understand that all chiropractic services: dry needling, adjustments, FSM, Laser, Piezo wave, and any and all other services offered, are available and performed on me with my full consent and understanding, and I release Alton Chiropractic, Dr. Michael Alton, and any and all staff from any claims, actions, causes of actions, suits, damages or demands of any kind which may occur as a result of any injury including death sustained by myself or others resulting from the receipt of services.

I Agree

I hereby give my consent to the chiropractic treatment and procedures, including tests to be conducted in managing my condition(s).

I understand that in such chiropractic treatment, the doctor will use his/her bare hands, including, but not limited to use of any mechanical device in order to move my joints.

I understand that in such movement of joints, I may feel and/or hear some popping of my joint(s).

I have been informed that in chiropractic treatment or management of conditions, such are the known risks:

Soreness or symptoms or Increased pain by which such may occur temporarily after the first few treatments.

Nausea or dizziness. In this event where these symptoms are felt, I shall inform my chiropractor right away.

Fractures. It is my duty to notify my chiropractor in case I am aware that I have weak bones or have been diagnosed with any bone-weakening disease such as osteoporosis. The chiropractor may also halt the procedure if he or she finds that such or similar condition is detected by him or her while under the latter's care.

Spinal disc conditions like bulges or herniations. In such a case, I will have to notify my chiropractor when such symptoms arise.

Stroke. I am informed that there has been no known direct association between chiropractic treatments and stroke. However, for safety purposes, I shall inform my chiropractor of any symptom of neck pains and headache which are known symptoms of a stroke.

I understand that chiropractic treatment is not a perfect or exact science and is not an alternative method that guarantees results.

I further agree that if I choose to add Cryo T-Shock, FSM, Class IV laser or any other treatment plan, this waiver covers those treatments and risks, as well.

I Agree

In consideration of the risk of injury while participating in Chiropractic Care and Treatment, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation, and do hereby release and forever discharge Alton Chiropractic, Dr. Michael Alton, and any and all staff members, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned treatments, including traveling to and from. I understand and recognize that the chiropractic care and therapy may include, but are not limited to, chiropractic adjustments and manipulative therapies to all of the joints of the body, active release deep tissue massage technique and instrument assisted soft tissue manipulation to the soft tissues of the body, static and dynamic stretches to the joints and soft tissues of body that involve resistance bands, and exercises that involve manipulating free weights, resistrance bands and bodyweight movements. I am voluntarily participating entirely at my own risk. I am aware of the risks associated with traveling to and from as well, which may include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and death. I understand that these injuries or outcomes may arise from my own or others' negligence. Nonetheless, I assume all related risks, both known or unknown to me. I hereby release Alton Chiropractic, Dr. Michael Alton, and their directors, affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns I agree to indemnify and hold harmless Alton Chiropractic and Dr. Michael Alton against any and all claims suits or actions of any kind whatsoever for liability, damages, compensation or otherwise caused by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by or against me or by or against anyone else acting on my behalf. If Alton Chiropractic or Dr. Michael Alton incur any of these types of expenses, I agree to reimburse them. I acknowledge that Alton Chiropractic, Dr. Michael Alton, and their directors, officers, volunteers, representatives and agents are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Alton Chiropractic. I expressly agree to release and discharge Alton Chiropractic and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against Alton Chiropractic for personal injury or property damage. This waiver and release includes all injuries which may occur, regardless of negligence, as a result of: 1. Uses of all amenities and equipment 2. Sudden and unforseen malfunction of amenities and equipment 3. Slipping and/or falling while at the premisis or any areas adjacent thereto 4. And any other areas where activites are conducted To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence on the part of Alton Chiropractic, its agents, and employees. In the event that I should require medical care or treatment as a result of my participation, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. This Agreement was entered into at arm's-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both the Participant and Alton Chiropractic agree that this Agreement is clear and unambiguous as to its terms, and that no other evidence will be used or admitted to alter or explain the terms of this Agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into. In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect, so long as the clause severed does not affect the intent of the parties. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited. Arbitration. All claims and disputes arising under or relating to this Agreement are to be settled by binding arbitration in the state of Texas pursuant to the laws of the state of Texas. The arbitration shall be conducted on a confidential basis pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any decision or award as a result of any such arbitration proceeding shall be in writing and shall provide an explanation for all conclusions of law and fact and shall include the assessment of costs, expenses, and reasonable attorneys' fees. Any such arbitration shall be conducted by an arbitrator experienced in medical and chiropractic care and shall include a written record of the arbitration hearing. The parties reserve the right to object to any individual who shall be employed by or affiliated with a competing organization or entity. An award of arbitration may be confirmed in a court of competent jurisdiction.

I Agree

Patient Acknowledgement and Receipt of Waiver and Release of Liability I agree to participate in Alton Chiropractic and other offered therapies. The undersigned does hereby acknowledge that I have received a copy of this office’s Notice Waiver and Release of Liability and has been advised that a full electronic copy of this Notice and that a printed copy is available upon request.

Patient signature (or Legal Guardian)

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May 12, 2024

In the event that the participant is a minor under the age of consent (18 years of age), then this release must be signed by a parent or guardian as defined by State Law, as follows: I hereby certify that I am the parent or guardian of person named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

Parent / Guardian Name: Relationship to Minor

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May 12, 2024

First Patients Name

First Name*

Middle Name

Last Name*

Phone*

First Patients Date of Birth*

First Patients Signature*

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Second Patients Name

First Name*

Middle Name

Last Name*

Phone*

Second Patients Date of Birth*

Third Patients Name

First Name*

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Last Name*

Phone*

Third Patients Date of Birth*

Fourth Patients Name

First Name*

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Last Name*

Phone*

Fourth Patients Date of Birth*

Fifth Patients Name

First Name*

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Last Name*

Phone*

Fifth Patients Date of Birth*

Sixth Patients Name

First Name*

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Last Name*

Phone*

Sixth Patients Date of Birth*

Seventh Patients Name

First Name*

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Last Name*

Phone*

Seventh Patients Date of Birth*

Eighth Patients Name

First Name*

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Phone*

Eighth Patients Date of Birth*

Ninth Patients Name

First Name*

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Last Name*

Phone*

Ninth Patients Date of Birth*

Tenth Patients Name

First Name*

Middle Name

Last Name*

Phone*

Tenth Patients Date of Birth*

Patients Address

Address Line 1:*

Street address, P.O. box, company name, c/o

Address Line 2:

Apartment, suite, unit, building, floor, etc.

Country:*

City:*

State/Province:*

Zip/Postal:*

Parent or Guardian's Email Address

Email*

Confirm Email*

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Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*

Parent or Guardian's Date of Birth*

Parent or Guardian's Signature*

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Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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