RESPONSIBLITY OF PAYMENT, CONSENT FOR EXAMINATION AND TREATMENT AND RISK OF TREATMENT. I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and myself. Furthermore, I understand that the Doctor’s office will prepare necessary reports and forms to assist me in making collection from the insurance and that any amount authorized to be paid directly to the Doctor’s office will be credited to my account on receipt. However. I clearly understand that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services offered me will be immediately due and payable.I hereby request and consent to performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and , if necessary, diagnostic x-rays, on me by the doctor of chiropractic and/or anyone working in the clinic authorized by the doctor of chiropractic.I have had an opportunity to discuss with the doctor of chiropractic/staff member and/or staff member and/or with office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.I further understand and am informed that, as in all healthcare, in practice of chiropractic there are some very slight risks to treatment, including, but not limited to, muscle strains, sprains, rib fractures, disc injuries, and strokes. I do not expect the doctor to be able to anticipate and explain all the risks and complications and I wish to rely on the doctor to exercise judgement during the course of the procedure that the doctor fells at the time, based upon facts then known, and is in my best interests.I have read and understand the above and I consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic for my present condition, and future conditions for which I may seek care. I realize that I may ask any questions to the doctor of chiropractic either before or after I sign this consent, and I understand that my consent can be withdrawn at any time.ASSIGNMENT OF BENNEFITS & MEDICAL RELEASEI hereby authorize payments to be made directly to the Storey Chiropractic Clinic (“Clinic”) for any and all such sums as may be due and owing for services rendered to me by Clinic. Further, I authorize the withholding of any sums as may be due and owing form any disability benefits, medical payment benefits, no-fault benefits, health and accident benefits, or any other type of available insurance benefits, as well as proceeds arising from settlement, judgement or verdict rendered in my favor, in order that such sums may be paid directly to the Clinic. Further, I assign to the Clinic any and all rights, claims of action I may have against any insurance company, to include my own, arising from the recovery of benefits for payment of services provided to me by the Clinic. In event that payment by insurance company is refused upon demand by either myself or the Clinic, I authorize the Clinic to compromise, settle or otherwise resolve any claim or cause of action which I may have against the insurance company. I understand and agree that I remain personally responsible for the total due and owing for services provided to me by the Clinic, to include any such amount as may remain due and owing following such compromise, settlement or resolution of insurance benefits. I permit this office to endorse co-issued remittances for the conveyance of credit to my account.I understand and agree that payment for services provided to me by the Clinic are due and owing immediately upon the rendering of such services. I understand and agree that if payment for such services is not made when due and owing, the Clinic may file a lien for reasonable charges for services against any and all causes of action, suits claims, counterclaims or demands accruing to me or my legal representative, on account of the injuries given rise to such causes of action and for which treatment was rendered. I understand and agree that the Clinic may demand that payments for Clinic services provided to me be kept current, and that any amount due and owing for more than thirty (30) days shall accrue interest at the rate of three percent (3.0%) per month until pain in full. This document authorizes Storey Chiropractic Clinic, P.C. to release medical information and reports as deemed necessary by the physician to my insurance company and/or attorney.I certify that I’m the patient or legal guardian._________________________________________________________Date________________________Signature of Patient_________________Initial of office witness