I clearly understand and agree that all services rendered to 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 or treatment that any fees for professional services rendered to me will be immediately due and payable. I understand and agree that if charges are to be filed with an insurance carrier and unpaid/denied, I am responsible for payment. Furthermore, I understand that DR. MEL YOUNGS, D.C., P.A. will prepare any necessary forms to assist me in making collection from my insurance carrier and that any amount authorized will be paid directly to DR. MEL YOUNGS, D.C., P.A. and will be credited to my account upon receipt. I understand that DR. MEL YOUNGS, D.C., P.A. is acting solely as an agent for me in filing to my insurance carrier for benefits assigned to me and authorize release of any information required to support my claim. However, DR. MEL YOUNGS, D.C., P.A. can assume no responsibility for guaranteeing payment of covered services. I understand that I am financially responsible for all charges whether or not paid by my insurance carrier as well as any attorney fees and costs incurred to collect for these services.

I clearly understand that I am personally responsible for payment of any professional services rendered to me. I have been explained the potential benefits and side-effects of Class IV Laser Therapy. I understand the Doctor's recommendations for a series of treatments, but I also understand that there is no guarantee of results. I understand that these treatments are non-transferable.

Laser therapy is a safe and effective therapy that is FDA cleared for the temporary relief of pain and reduction of symptoms associated with mild arthritis and muscle pain. Laser also promotes relaxation of muscle spasm and promotes vasodilation. Adverse effects from laser therapy are normally rare and temporary.

Pain relief from laser therapy may be dramatic and substantial, lasting for hours, days or weeks. However, your results may be minimal or insignificant. Adverse effects of laser therapy may occur from multiple causes including hypersensitivity, preexisting health conditions, thermal effects, excessive pressure from probe, and laser over-stimulation. Laser light can damage the retina in your eye. Always wear the laser protective glasses provided.

The most common adverse effects are:
1. Temporary increase in pain during application of laser.
2. Temporary increase in pain the following day after laser therapy.
3. Mild bruising from vasodilation or direct pressure of laser tip.
4. Temporary dizziness.
5. Reactions when photosensitizing drugs are used with laser therapy.

I understand the risks of laser therapy and agree to the treatment program outlined by my doctor.