PLEASE READ AND ACCEPT IN ORDER TO BE TREATED AT THE OFFICE:
WE INVITE YOU TO DISCUSS WITH US ANY QUESTIONS REGARDING OUR SERVICES. THE BEST HEALTH SERVICES ARE BASED ON A FRIENDLY, MUTUAL UNDERSTANDING BETWEEN YOU AND THE DOCTOR AND HIS STAFF. OUR POLICY REQUIRES PAYMENT IN FULL FOR ALL SERVICES RENDERED AT THE TIME OF THE VISIT UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE WITH THE OFFICE MANAGER OR DR. DAVID ALLAN.
IF YOUR ACCOUNT IS NOT PAID WITHIN 90 DAYS OF THE DATE OF THE SERVICE AND NO FINANCIAL ARRANGEMENTS HAVE BEEN MADE, YOU WILL BE RESPONSIBLE FOR ANY EXPENSES INCURRED IN THE COLLECTION OF YOUR ACCOUNT. I AUTHORIZE THE STAFF TO PERFORM ANY NECESSARY SERVICES NEEDED DURING DIAGNOSIS AND TREATMENT. I ALSO AUTHORIZE THE PROVIDER TO RELEASE ANY INFORMATION REQUIRED TO PROCESS INSURANCE CLAIMS.
I UNDERSTAND THE ABOVE INFORMATION AND GUARANTEE THIS FORM WAS COMPLETED CORRECTLY TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY HEALTH. WE RESERVE THE RIGHT TO CHARGE FOR APPOINTMENTS CANCELED OR BROKEN WITHIN 24 HOURS NOTICE. ARRANGEMENTS ARE MADE FOR THE OFFICE TO BILL INSURANCE, I ASSIGNED DIRECTLY TO DR. DAVID ALLAN, DC ALL INSURANCE BENEFITS UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY INSURANCE.
INFORMED CONSENT TO CHIROPRACTIC TREATMENT:
CONGRATULATIONS FOR CHOOSING THE SAFEST AND MOST NATURAL HEALTHCARE PROGRAM EVER CONCEIVED: CHIROPRACTIC!
THIS PAINLESS, LOGICAL, AND EFFECTIVE APPROACH TO HEALTH HAS BEEN SERVING EVERYDAY PEOPLE FOR OVER 100 YEARS.
IT IS LICENSED IN EVERY STATE AND IN MANY COUNTRIES AROUND THE WORLD. CHIROPRACTIC HAS THE LEAST CHANCE OF SIDE EFFECTS OF ANY OTHER TYPE OF HEALTHCARE. AS WITH ANY HEALTHCARE PROCEDURE, THERE ARE CERTAIN COMPLICATIONS WHICH MAY ARISE DURING CHIROPRACTIC MANIPULATION AND THERAPY. DOCTORS OF CHIROPRACTIC ARE REQUIRED TO ADVISE PATIENTS THAT THERE ARE RISKS ASSOCIATED WITH SUCH TREATMENT, IN PARTICULAR, YOU SHOULD NOTE:
SOME PATIENTS MAY EXPERIENCE SOME STIFFNESS OR SORENESS FOLLOWING THE FIRST FEW DAYS OF TREATMENT.
SOME TYPES OF MANIPULATION HAVE BEEN ASSOCIATED WITH INJURIES TO THE ARTERIES OF THE NECK LEADING OR CONTRIBUTING TO SERIOUS COMPLICATIONS INCLUDING STROKE. THIS OCCURRENCE IS EXCEPTIONALLY RARE AND REMOTE. HOWEVER, YOU ARE BEING INFORMED OF THE POSSIBILITY REGARDLESS OF THE EXTREME REMOTE CHANCE.
I WILL MAKE EVERY EFFORT TO SCREEN FOR ANY CONTRAINDICATIONS TO CARE; HOWEVER, IF YOU HAVE A CONDITION THAT WOULD OTHERWISE NOT COME TO MY ATTENTION, IS YOUR RESPONSIBILITY TO INFORM ME.
OTHER COMPLICATIONS MAY INCLUDE FRACTURES, DISC INJURIES, DISLOCATIONS, MUSCLE STRAIN, CERVICAL MYELOPATHY, CASTRO VERTEBRAL STRAINS AND SEPARATIONS, AND BURNS. THE PROBABILITIES OF THESE COMPLICATIONS ARE RARE AND GENERALLY RESULT FROM SOME UNDERLYING WEAKNESS OF THE BONE OR TISSUE WHICH I CHECK FOR DURING THE HISTORY, EXAMINATION, AND X-RAY (WHEN WARRANTED).
THERE IS NO ABSOLUTELY KNOWN MATERIAL RISK OF CHIROPRACTIC CARE BEING GREATER THAN RISKS FROM MEDICAL TREATMENT. IN FACT, WHEN ALL THE FACTORS ARE TAKEN TOGETHER, DEATHS AND INJURIES FROM A COMBINATION OF MEDICAL MISTAKES AND INTENTIONAL DRUGS DWARF ANY INJURIES FROM CHIROPRACTIC.
RISK OF STROKE FROM CHIROPRACTIC? VIRTUALLY ZERO CHANCE OF STROKE FROM CHIROPRACTIC. THE LARGEST STUDY EVER DONE… THE 2008 STUDY IN CANADA LOOKING AT 12 MILLION PEOPLE OVER NINE YEARS, SHOWED THAT 53% OF STROKES HAD VISITED THE MD WITHIN 30 DAYS PRIOR, WHILE ONLY 4% HAD VISITED THERE DR. OF CHIROPRACTIC. NO EVIDENCE OF EXCESS RISK OF STROKE ASSOCIATED WITH CHIROPRACTIC CARE. I CAN KNOWLEDGE I HAVE HAD THE OPPORTUNITY TO DISCUSS THE ASSOCIATED RISKS AS WELL AS THE NATURE AND PURPOSE OF TREATMENT WITH MY CHIROPRACTOR.
BY SUBMITTING THIS ONLINE FORM, I CONSENT TO THE CHIROPRACTIC TREATMENTS OFFERED AND RECOMMENDED TO ME BY MY CHIROPRACTOR, INCLUDING SPINAL MANIPULATION. I INTEND THIS CONSENT TO APPLY TO ALL MY PRESENT AND FUTURE CHIROPRACTIC CARE.