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Connecticut Physical Medicine Office in Waterbury Connecticut

Consent to Treat Form

Please complete this form online and click send at the bottom.

I hereby request and consent to the treatment plan as explained to me for my medical symptoms, complaints, illness. If I am referred for chiropractic or physical therapy services, I understand it is part of this practice and consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic and physical therapy procedures, including various modes of physical therapy on me (or on the patient named below, for whom I am legally responsible) by the chiropractors and physical therapists who now or in the future work at the clinic or office listed above or any other office or clinic.

I understand and am informed that, as in the practice of medicine, in the practice of physical therapy and chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor and/or physical therapist to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor/therapist to exercise judgment during the course of the procedure which the doctor/therapist feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. By signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

All procedures (medical, chiropractic and physical therapy) will be covered by this consent and will be in effect until the patient revokes the consent in writing to this practice.

I understand that results are not guaranteed.


Parent/Guardian E-signature:



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