Welcome to our office!
Paediatric Intake Form
CLINICAL CONSENT, PRIVACY & INSURANCE POLICIES
Consent to Chiropractic Care & to the Collection, Use, and Disclosure of Personal Information
INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE:
Physicians, Chiropractors, Osteopaths and Physiotherapists are required to advise patients of benefits and risks including sprain/strain, rib fracture, disc herniation and neck problems of the following: There have been very rare incidents of injury to the vertebral artery during the course of treatment. This has caused strokes or stroke like occurrences, which are usually of a temporary nature. The chances of this happening are rare. Tests, with or without x-rays have been performed on you to minimize these risks to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy for neck conditions. The Chiropractor may also scan your feet for custom made orthotics to determine if you may benefit from them. The fee for this scan is included with your New Patient Examination. The Chiropractor may also suggest other treatments, including: Low Level Lasers, Shockwave Therapy & Kinesio Taping in addition to Chiropractic adjustments. All of the services are none invasive and promote faster healing and pain relief. As Chiropractors we do not claim to treat any specific diseases or ailments. (This includes: High Blood Pressure, Diabetes, ADHD e.c.t). We simply work with the spine to attain optimal alignment and nervous system function. If you have any questions about this, please ask your Chiropractor.
In accordance with the privacy act effective January 2004, we must ask for your informed consent. This means we want you to understand what we do with personal information. Your signature below allows us to obtain this information to open a confidential file for you. This is the only reason we collect your personal information. I understand that to provide me with Chiropractic goods and services, Lifetime Wellness Center will collect some personal information about me (e.g.: telephone number, birth date, address, etc.).
We use and disclose your personal health information to:
· treat and care for you,
· plan, administer and manage our internal operations,
· conduct quality improvement activities (such as sending patient satisfaction surveys)
· compile statistics,