Contact Us - Dr. Todd M. Wulf

	Physical Therapy
	Chiropractic
	Spinal Decompression

	How It Works?
	Proof It Works?
	Thinking About Back Surgery?

	Whiplash & Auto Injury
	Treatment Offered

	Headache Relief Center
	Back Pain Relief Center
	Fibromyalgia Relief Center
	Neck Pain Relief Center
	Whiplash Relief Center
	Spinal Decompression Ctr.

	HIPAA Information & Consent Form
	Patient Application Form
	Records Release Consent Form

My husband (the skeptic) has noticed a change in me since I’ve begun my care here. He says I have more energy and have a more positive disposition. I have always known that the spine has so much to do with our overall well-being and this is proof to me that chiropractic care works.

Kendra B.

AUTHORIZATION FOR DISCLOSRE GENERAL CONSENT FORM

Name
Birth date
SS#
Authorize	ANY MEDICAL PROVIDER
To Disclose To	THE WULF CLINIC or authorized representative, providing ID verification.

THE FOLLOWING INFORMATION FROM MY CLIENT FILE OR RECORDS:

Client information and services provided (types and date only).
Summary of Assessment and Treatment.
Physical examinations or other medical information.
ANY Radiology reports and films needed for diagnosing or treating.

The purpose for disclosure is records review. The consent to disclose information from my records may be revoked by me or anyone holding power of attorney if such is among the enumerated powers, at anytime, except to the extent that the consent has been relied on and action has been taken thereon.

This consent becomes effective on the date that it is signed. This information will be released ONLY to the person or organization above named. It will not be disseminated to anyone, for any purpose, other than the one specified.

Client Signature:.........................................................................................	Date:
Winess Signature :.....................................................................................	Date: