I have read and agree to the Chiropractic Informed Consent to Treat. I intent 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.

I authorize the health care personnel of Dr. Robin C. Harkins D.C. to evaluate the information I have provided them and the information they will further gather to consider various options available to me to improve my health, vitality and well-being and not for treatment, or "cure" of disease.

I give the office staff permission to contact me by phone, email, mail or fax to discuss with me or inform me about what might be helpful for me or my family. I understand this permission to contact me can be rescinded by me at any time* I choose.

*Rescinding of permission to contact accepted in writing only.