Notice of Privacy Practices Acknowledgement Form Schroeder Family Chiropractic’s Notice of Privacy Practices provides information about how we may use and disclose Protected Health information about you. It also provides information on what your rights are regarding your Protected Health Information as outlined by the Health Insurance Portability and Accountability Act of 1996. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by making a request. By signing this form, I acknowledge that I have received a copy of the Notice of Privacy Practices or had the opportunity to review the notice. _____________________________________________ (Print Patient Name) _____________________________________________ (Patient or Legal Representative Signature) (Date) _____________________________________________ (Witness Signature) (Date)
www.schroederfamilychiro.com Informed Consent Document PATIENT NAME: _________________________________________________________ To the Patient: Please read this entire document prior to signing it. It is important you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the Chiropractic Adjustment. The primary treatment used by Doctors of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement. Analysis / Examination / Treatment As a part of the analysis, examination, and treatment, you are consenting to the following procedures. -- spinal manipulative therapy -- palpation -- vital signs -- range of motion -- ultrasound -- muscle stim -- muscle strength testing -- postural analysis -- hot/cold therapy -- basic neurological testing -- orthopedic testing The material risks inherent in chiropractic adjustment. As with any healthcare procedure, there are certain complication which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor will make every reasonable effort during the examination to screen for contraindications to care; however if you have a condition that would otherwise not come to the Doctor’s attention it is your responsibility to inform the Doctor. The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.
The availability and nature of other treatment options. Other treatment options for your condition may include: Ã¯‚Â· Self-administered, over-the-counter analgesics and rest Ã¯‚Â· Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers Ã¯‚Â· Hospitilization Ã¯‚Â· Surgery If you chose to use one of the above noted “other treatment” options you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Dated: ___________________________ Dated: ________________________ _________________________________ ______________________________ Patient’s Name Doctor’s Name _________________________________ ______________________________ Signature Signature CONSENT TO TREATMENT (MINOR) I hereby request and authorize Dr. Schroeder / Dr. Cullens to perform diagnostic tests and render Chiropractic adjustments and other treatment to my minor son/daughter: ______________________. This authorization also extends to all other Doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion. As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation, or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I have read or have had read to me the above explanation of the Chiropractic adjustment and related treatment. I have discussed it with Dr. Schroeder / Dr. Cullens and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. Dated: ___________________________ _________________________________ Patient’s Name _________________________________ Signature of Guardian
www.schroederfamilychiro.com PREGNANCY RELEASE: INFORMED CONSENT TO X-RAY (to be completed on day of x-ray) PLEASE READ THIS ENTIRE FORM. All women of childbearing age must sign this release and check any appropriate category. o I have had a hysterectomy or tubal ligation. o I am presently in menopause or post-menopause. “This is to certify that, to the best of my knowledge, I am not pregnant at this time. I hereby authorize Schroeder Family Chiropractic to take x-rays as necessary to determine the status of my spine. I will assume all responsibility for any effects on a fetus potentially present.” Print name: ___________________________ Signature: ______________________________________ Date: ________________________________ Witness: _____________________________ INFORMED CONSENT NOT TO X-RAY (to be completed on day of x-ray) o I am pregnant. "This is to certify that, to the best of my knowledge, I am pregnant at this time. I DO NOT authorize Schroeder Family Chiroprac