• Wells Chiropractic
    1001-6 East WT Harris Blvd.
    Charlotte NC 282132

    Consent For Treatment and Authorization to Perform X-Rays
    I have been informed that diagnostic x-rays are advisable in my case so that a complete analysis can be made of my present musculoskeletal problem (or illness). I authorize any radiographic examination necessary to diagnose and administer whatever treatment necessary to treat my present problem.

  • To the best of my knowledge I am NOT pregnant and the doctor has my permission to x-ray me for diagnostic interpretation