I understand that, as in the practice of medicine, in the practice of chiropractic wellness care there are some risks to treatment, including and not limited to, fractures, disc injuries, strokes, dislocations and sprains.  I do not expect the doctor to anticipate and explain all risks and complications.  I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest.

I understand that I am employing the services of N. Harmony Wellness. so that I can obtain information and guidance about health factors within my own control (diet, nutrition, supplements, and related behaviors) to nourish and support my overall health and wellness. I understand the benefits and risks if any are associated. I understand that results are not guaranteed. I understand that Dana A Cooper, D.C. is a Licensed Chiropractic. I understand N. harmony Wellness Telehealth Services is not a substitute for medical diagnosis, treatment, and/or care of a disease by an in person medical provider. I understand that N. Harmony Wellness will keep appointment notes as a record of our sessions. These notes will document the topics discussed, interventions/plan, goals, and progress. Records will be kept securely. All health history, personal information and medical records shared with N. Harmony Wellness will be kept strictly confidential unless I have signed an authorization for release or where disclosure is required by law (see privacy notices). 
I understand that N. Harmony Wellness has a 24-hour cancellation policy, and I am aware that I may be charged for 50% of the appointment cost if proper notice is not given. Wellness services may be terminated at the discretion of Dana A Cooper, D.C.  if written notification is provided to a client thirty (30) days in advance of the final appointment. This will include a listing of referrals for continuity of care. I certify that all information contained in this form is correct and do not hold Dana A Cooper, D.C. or N. Harmony Wellness responsible for any missing, incomplete, or incorrect information. I agree to the terms above.