Informed Consent

By booking online, I agree to the following:

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.


Cancellation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the chiropractors’ day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, will be charged a cancellation fee. Late arrivals can result in a missed appointment, so please call ahead as soon as possible to determine if a re-schedule is needed. 919-552-6559

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Regarding Chiropractic adjustments, Modalities, and Therapeutic procedures

I have been advised that chiropractic care, like all forms of healthcare, holds certain risks. While the risks are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and minor fractures may occur. Strokes, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. Treatment objectives as well as risks associated with chiropractic adjustments, and all other procedures, such as cupping, heat and stem, and therapies provided at Hometown Chiropractic have been explained to my satisfaction and I have conveyed my understanding of both to the doctor.

After careful consideration, I do hereby consent to treatment by any means, method, and or techniques that the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

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Thanks so much for helping our office run smoothly.

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