I certify that the information provided is accurate to the best of my knowledge. I further understand that giving incorrect information can be dangerous to my health. I authorize this office to release any information, including the diagnosis and the records of any treatment or examination rendered to me during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Total Health of Wesley Chapel, Inc. I further understand that my chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services on my behalf or my dependents.
I acknowledge that I have read and understand the Informed Consent for Chiropractic Treatment and understand the risks of the recommended treatment. The treatment and the risks of the treatment, along with the alternatives to treatment including but not limited to one of the following options (orthopedic or neurosugical evaluation and/or alternative medical doctors) have also been fully verbally explained to me by the doctor. I understand and consent to treatment being delivered by Dr. Ladanyi and/or (whomever he may designate as his assistants). I nonetheless do consent for Total Health of Wesley Chapel Inc. to provide their recommended chiropractic therapy. I also certify that no guarantee or assurance of results has been made.