Fillable New Patient Forms (Page 3 of 3) in pdf

Consent to Initiate Care

At our office, we have one simple goal.

We want to change your life by rendering the highest quality

Chiropractic care. We do this by specific scientific chiropractic adjustments designed to remove vertebral

subluxations affecting your nervous system and interfering with your inborn given innate ability to be healthy. To

accomplish this goal, we must work together. We believe good Chiropractic care requires a partnership

between you and us. Please read over our clinic’s procedures to understand how our clinic functions, so that

you can be an active participant in your care. If you have any questions please feel free to ask us.

To initiate care at our facility, there are two required visits you will be scheduled for, other than this visit, your

Initial Examination visit. If you cannot attend either of these two subsequent visits, the negative impact on your

care will be profound, and we cannot in good conscious initiate your care. These required visits are:

Your Brief Report of

Findings:

This visit is your first visit after your examination. This is where the doctor tells

you if he feels chiropractic can help you and briefly explains your care. In most instances you will

receive your fist adjustment on this visit, unless you would prefer to receive care at that time or to wait

until after your X-ray Report.

Doctor's Report:

This will be your longest visit at our clinic and will consist of a detailed report of

findings with recommendations for your care. Also included will be recommendations on what to do

between visits and a detailed explanation of your care plan. Any x-rays taken will be reviewed at this

time. We highly recommend that spouses and adult family members attend this visit with the patient.

Due to the time required, there are only certain times this visit is given. Check with our receptionist or the

doctor for available times. Total visit time about 50 - 70 minutes.

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are

most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc, and

although rare, minor fractures have been associated with chiropractic adjustments.

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures,

provided ave been explained to me to my satisfaction and I have conveyed my understanding of both to the

doctor.

After careful consideration, I do hereby consent to treatment by any means, method, and or

techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course

of my care.

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health

Insurance Portability & Accountability Act of 1996. (HIPAA). I understand that this information can and will be

used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who

may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations, such as quality assessments and physicians certifications.

I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete

description of the uses and disclosures of my health information. I also understand that I may request, in

writing, that you restrict how my private information is used or disclosed to carry out treatment, payment, or

healthcare operation. I also understand that you are not required to agree to my requested restrictions, but if

you do agree, then you are bound to abide by such restrictions.

Print your name ________________________________________________ Today’s date _______________________

Sign your name ______________________________________________________________

New Patient Forms Page 3

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