Consent Form

The Bluffs Chiropractic & Family Wellness

672 Gravois Bluffs Blvd. D

Fenton, MO 63026

General Patient Information – Consent to Examination

Acknowledgement of Financial Responsibility

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

Patient’s Rights:

The Bluffs Chiropractic & Family Wellness respects the unique differences of our patients, and will ensure that health care ethics are maintained for all patients. The following rights will be exercised on our patients’ behalf.

1. The patient has the right to considerate and respectful care.

2. The patient has the right to and is encouraged to obtain from his/her chiropractor relevant, current, and understandable information concerning diagnosis, treatment and prognosis.

3. The patient has the right to know the identity of their chiropractor and all office staff involved in their care.

4. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law, and to be informed of the consequences of this action.

5. The patient has the right to every consideration of privacy.

6. The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential, except in cases when reporting is permitted or required by law.

7. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by the chiropractor of available and realistic patient care options.

The primary treatment used at the clinic is spinal manipulative therapy. It is likely that spinal manipulative therapy will be used as part of your treatment. Spinal manipulative therapy includes use of the doctor’s hands and mechanical instruments upon your body in such a way as to mobilize your joints. This movement may cause an audible“pop” or “click” such as experienced when you “crack” your knuckles. You may also feel a sense of movement.

All patient care, including chiropractic treatment, has the potential for negative effects. The risks associated with chiropractic treatments include, but are not limited to, dislocations and sprains, disc injuries, fractures, and strokes. These negative effects are very rare and will be fully explained to you by your doctor after the examination has been completed and a treatment plan has been fully developed. Your chiropractor will formulate a treatment plan and will recommend what they feel is in your best interest.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which your doctor looks for during your initial consultation, your examination and while reviewing your x-rays. Stroke has been the subject of tremendous disagreement. The incidence of a stroke is exceedingly rare and is estimated to occur between one in one million and one in five million adjustments of the neck. The other complications are also generally described as rare.

Remaining untreated may allow the formation of adhesions and reduce mobility of your joints which may set up a pain reaction further reducing mobility. Over time this process may compromise your recovery making treatment more difficult and less effective the longer it is postponed.

Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest; Medical care & prescription drugs such as anti-inflammatory, muscle relaxants, & pain killers; Physiotherapy; Hospitalization; 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 care physician.

I understand and agree that the health and accident insurance policies are an arrangement between the insurance carrier and me. Furthermore, I understand that the doctor’s office will prepare all necessary reports and forms to assist mein making collection from the insurance company, and that any amount authorized will be paid directly to the doctor’s office and will be credited to my account on receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment.

I understand that I am financially responsible for all charges whether or not paid by said insurance. I, with this authorize a said assignee to release all information to secure payment. I agree to pay a service charge on all delinquent amounts more than 30 days past due. This charge will be computed at a rate of 1 1\2% per month, 18% per annum. I will also be responsible for all costs incurred in the collection of my account.

I understand that The Bluffs Chiropractic and Family Wellness can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communications comply with privacy regulations.

I understand that The Bluffs Chiropractic and Family Wellness can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. I also understand that the Company can employ and use a third-party automated system to reach out me for the purpose of "confirm", "reschedule" or "cancel".

Prior to establishing a treatment plan, the doctor must perform an examination in order to determine the exact cause of your complaint. During this examination the doctor will perform some procedures or maneuvers intended to reproduce your symptoms, which will allow for a better understanding of the nature of your condition and for the development of an appropriate treatment regimen. There is a slight possibility that these maneuvers may temporarily aggravate your symptoms. The doctor will also take x-rays if needed to better diagnose your problem.

I hereby authorize the doctor to treat my condition as he deems appropriate through adjusting my spinal column. I understand and agree that the amount paid for x-rays is for examination only and the x-ray negatives will remain the property of this office. I also agree that I am responsible for all bills incurred at the office. The doctor will not be held responsible for any preexisting medically diagnosed conditions, nor for any medical diagnosis.

By signing below I state that I want to investigate how chiropractic care can help me (or the patient listed below to whom I am the legal guardian) and consent to a chiropractic examination. Once a treatment plan is established, I will have the opportunity to discuss the treatment plan with my doctor and to consent to the proposed care. I intend the consent to cover any examinations for my present condition and for any future condition for which I seek treatment at The Bluffs Chiropractic & Family Wellness (for the conditions(s) of the patient listed below for which I am the legal guardian).

Thank you for taking the time to fill out this form.

Monday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Tuesday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Wednesday  

9:00 am - 11:00 am

1:30 pm - 5:00 pm

Thursday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Friday  

Closed

Saturday  

Closed

Sunday  

Closed

We look forward to hearing from you

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Please do not submit any Protected Health Information (PHI).

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