Terms of Acceptance:
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- Bethanie Nicholson
- 5 years ago
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3 Terms of Acceptance: When a patient seeks chiropractic health care and we accept them for such care, it is essential for us both to be working towards the same objective. Chiropractic has only one goal: to eliminate misalignments within the spinal column and pelvis, which interfere with the body s nervous system and the musculoskeletal biomechanics. Adjustment: the correction of misalignments of joints. It is utilized in all the stages of care. This helps to reestablish communication between the brain and the body. Cranial Laser Therapy: a procedure utilizing low-level coherent light on specific cranial points and brain areas with the objective of reducing musculoskeletal pain, normalizing muscle tone, and enhancing cortical function. The laser light on the cranium stimulates the release of neuropeptides similar to the body s own morphine. Exercise: specific postural movements used in corrective care to obtain maximum spinal stability. Health: is the process of the body continually striving for optimum function. Chiropractic influences health by correcting a major cause of dysfunction. Subluxation: a misalignment of one or more of the bones in the spinal column, or pelvis. They cause alterations in nerve function and biomechanics. This results in a significant decrease in the body s ability to achieve its maximum health potential. We use computerized postural examinations and X-rays to evaluate a patient for subluxations. We do not offer to diagnose or treat any disease or condition other than subluxations. However, we recognize that often people have diseases and conditions that may resolve while under chiropractic care. If during the course of chiropractic spinal examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. I, have read and fully understand the above statements and I therefore accept chiropractic care on this basis. I authorize Wise Chiropractic & Wellness to take any X-rays necessary during the course of my chiropractic care. I further recognize that at any time during the course of my care I may decline to have an X-ray examination. (Females Only) I recognize that it is my responsibility to notify the doctor if there is any possibility that I am pregnant. I will notify a doctor of Wise Chiropractic prior to any X-rays taken when I am possibly pregnant. I understand that I should refuse X-rays during anytime that I may be pregnant. (Under 18 Only) I being the parent or guardian of do hereby authorize, request and direct the Doctor s to perform in their judgment any necessary examination, X-ray and Chiropractic care. Parent/Guardian
4 Informed Consent to Chiropractic Treatment The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a click or pop, such as the noise when a knuckle is cracked, and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, laser therapy, therapeutic exercise, traction or muscle/massage therapy may also be used. Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as rare, about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered rare. Other treatment options which could be considered may include the following: Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases. Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. Unusual risks: I have had the following unusual risks of my case explained to me. I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment. Printed Name Signature Date
5 NOTICE OF PRIVACY FOR PATIENT S PROTECTED HEALTH INFORMATION This notice describes how health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This office abides by the terms described in this policy. This office uses and discloses your protected health care information for the following reasons: To share with other treating health care providers regarding your health care. To submit to Medicare to verify that treatment has been rendered. To determine patient s benefits in a Medicare plan. Releasing information required by State or Federal Public Health Law. To assist in overcoming a language barrier when caring for a patient. Business associates providing written assurances for your privacy have been attained. Emergency situations. Abuse, neglect or domestic violence. Appointment reminders to household members or answering machines. Sign-In logs may be disclosed to verify office visits. Appointment scheduling or payment, whereas your information may be overheard by others. Other: (Initial ) Any other uses or disclosures will only be made with your specific written prior authorization. You have the right to: Revoke authorization, in writing at any time by specifying what you want restricted and to whom. Speak to our privacy officer who is: Dr. Nick Wise and can be reached at: regarding privacy issues. Inspect, copy and amend your protected health information as allowed by law. Obtain an accounting of disclosures of your protected health information. To render a complaint to our privacy officer or the Secretary of Health and Human Services. This office reserves the right to change the terms of this notice and to make new notice provisions for all protected health information that it maintains. Patients may also get an updated copy upon request at any time by asking the staff. I acknowledge that I have received and reviewed this notice with full understanding. Patient Signature Date
Patient Information Form
Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
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Insurance. Patient Family Information. Patient Condition
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Last Name First Name M.I Nickname Address City State Zip_. Date of Birth Age Gender: M F Marital Status: S M W D INJURY INFORMATION
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