Greater Life Family Chiropractic
TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective.
Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be use to attain it. This will prevent any confusion or disappointment.
Adjustment: The adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Health: The state of optimal physical, mental and social well being, not merely the absence of disease or infirmity.
Vertebral subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
We do not offer diagnose or treat any disease. We only offer to diagnose either vertebral subluxations or neuro-musculoskeletal conditions. However, if during the course of a 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 another health care provider.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments.
I understand and agree that;
· All first visit charges are payable when services are rendered.
· Any fee paid for x-rays is for analysis only. The film itself is the property of this office.
· Health and accident insurance policies are an arrangement between my insurance carrier and me.
I understand Greater Life Wellness Center will prepare any necessary reports and forms to assist in making collection from my insurance company, and that any amount authorized to be paid directly to Greater Life Wellness Center will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me, I am personally responsible for payment, and I may be charged a finance charge of 1.5% per month on any outstanding balance due to me unless other payment arrangements have been made. I also agree to pay any and all fees that may be associated with any collection on my account. I certify that the information I give is true and understand that it is confidential.
I, ______________________________ have read and fully understand the above statements.
All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept chiropractic care on this basis.
Consent to evaluate and adjust a minor child:
I, _________________________ being the parent or legal guardian of ______________________________have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle. ________________________