Consent to Initiate Care
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Starting care in our office will consist of at least 2 appointments: Your initial visit and a follow up report of findings. More care may be suggested at your Report of Findings depending on your case.
Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. At Steinke Family Chiropractic the main method of adjusting is gentle and specific using an instrument called the Integrator. Our specific adjusting style is call Torque Release Technique. Our chiropractic method of correction is by specific adjustments to the spine.
HEALTH: A 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 to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, 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 a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
I acknowledge that I have read and fully understand the above statements. I give consent to Steinke Family Chiropractic to move forward with a chiropractic evaluation, any needed Radiologic Examinations, and any needed chiropractic adjustments at this time. I understand that I am not obligated to move forward with any further care unless I agree to such care at my report of findings.
Cost of Nerve Assessment/Initial Evaluation- $50
Cost of X-rays- $50 per set (typically two sets are taken)
Total Maximum Cost per person for Initial Evaluation: $150
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,