Welcome! This is what you can expect in your upcoming visits.
Please complete this simple admittance Form so we have an
understanding of your past and current health situation.
You will meet the doctor and discuss your health concerns.
We will conduct a thorough examination to locate the cause
of your problem and determine if you are a candidate for
chiropractic care. This includes a computerized assessment
of how well your nervous system is communicating with your
body. The assessment will include range of motion, surface
electromyography, which evaluates muscle function and balance
and an orthopaedic assessment. The doctor may also need additional
procedures, such as x-rays. If yours is a chiropractic case,
we will develop a plan to help you.
REPORT OF FINDINGS
At your second visit, the doctor will explain the
results of your examination. If we think that we can help you,
we will recommend a schedule of care created just for you. During
this time we will also explain our financial policies and determine
your insurance coverage, if applicable.
We find that when patients are empowered to help themselves,
they respond faster to care and remain healthier longer.
If we decide to accept your case part of your care involves an
opportunity to attend our health talk entitled health and healing
and inside out approach.
Please complete the following pages to save time and help us to
serve you better. Thank you.
Select options below indicating age at diagnosis and other relevant details.
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?
How do you want us to handle your problem?
Please read the following carefully before signing.
PLEASE READ CAREFULLY
In order for the Doctor of Chiropractic indicated below to make a
determination on the suitability of my case for chiropractic care,
I acknowledge and understand that I must complete a thorough
chiropractic evaluation, which may include a diagnostic radiographic
examination if clinically indicated. I do hereby request and consent
to the performance of such an evaluation by the Chiropractor indicated
below, or any party authorized to do so by that Chiropractor.
I have had the opportunity to discuss with the Doctor of Chiropractic
indicated below, or with any party authorized to do so by that Chiropractor,
about the nature and purpose of Chiropractic adjustments and other procedures.
I understand that Chiropractic care is considered very safe with an
extremely low risk rate. I further understand that there are, however,
some risks associated with chiropractic care, as there are with any and
all healthcare treatments. In healthcare, the matter of whether any treatment
is appropriate or not is determined by looking at the level of risk and
comparing this with the level of expected benefit.
In particular, I understand that in rare cases there have been reported
incidents of injury to the vertebral artery during the course of care to
the cervical spine by medical doctors, physiotherapists, and chiropractors.
However, the proposed mechanism of this injury is reproduced by a wide
variety of trivial neck movements, including turning your head to look
out the back of a car, or having a shampoo at a hair salon. This injury
is of concern because it may lead to a stroke. The risk of stroke after
cervical adjustment is estimated at 1 in 1,000,000, substantially lower
than that associated with any medical or other treatment medications or
procedures for the same symptoms. To put this in perspective, studies
that have assessed the risk from interventions a non-Chiropractor
commonly uses for the same complaints have found the following:
Risk of paralysis or stroke from surgeries for neck pain: 15,600 per million
Risk of death from surgeries for neck pain: 6,900 per million
Risk of serious gastrointestinal event from non-steroidal
anti-inflammatory drugs: 1,000 per million
I understand that while rare, some patients have experienced rib fractures or muscle
and ligament sprains or strains following spinal adjustments. I also understand that
there have been rare reported cases of disc injuries following cervical and lumbar
adjustments although no scientific study has ever demonstrated such injuries are
caused or may be caused by chiropractic treatment.
I understand and agree that health and accident insurance policies are an arrangement
between an insurance carrier and myself. Furthermore, I understand that the doctor’s
office will prepare any necessary reports and forms to assist me in making collection
from the insurance company and that any amount authorized to be paid directly to the
doctor’s office will be credited to my account on receipt. However, 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 at this office, any outstanding charges for professional services rendered
me will be immediately due and payable.
I have read and understood the above, and I have had sufficient opportunity to discuss
its content with the Doctor of Chiropractic indicated below. I do hereby request and
consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic
indicated below, for my present condition and for any future conditions for which I
may seek care. I also agree to payment for all services rendered.
* Please read and agree to the terms
Today's Date: 16 Jul 2019