Dr. Aaron Rickelman, Dr. Abbi Rickelman, Dr. Brady Dougherty
1360 NW 18th Street, Suite 101, Ankeny IA 50023
Phone: 515.957.4042 Fax: 515.598.7855
New Patient Intake Form
Past Health History
Please sign below if we have permission to release records to the above physician should the need arise.
Family Health History
Social and Occupational History
Review of Systems
Please indicate below if you have experienced any of the following.
Financial Agreement Form
Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully. If you have any questions, do not hesitate to ask. Appointments1. We value the time we have set aside to see and treat you. For this reason, it is our intent to not double book appointments. If you are not able to keep an appointment, we would appreciate 24-hour notice prior to your scheduled appointment. Failure to do so could result in cancellation fees.2. If you are late for your appointment (>15 minutes), we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment.3. Missed appointments will be subject to cancellation fees.4. We strive to minimize any wait time; however, emergencies do occur and will take priority over scheduled visits. We appreciate your understanding. Financial Responsibility1. According to your treatment plan, you are responsible for all balances accrued.2. The patient has three months to make a payment on accrued/accruing balance. If no payment has been made on a balance after 3 months, the physician has the right to file the responsible party to a collection agency. The financially responsible party of the account will be subject to fees associated with the collection agency and legal services.3. We accept cash, checks, debit cards, or Visa and MasterCard credit cards.4. In the event of a missed appointment not cancelled at least 24 hours in advance a fee of $25.00 will apply. A $40 fee will be charged for any checks returned for insufficient funds.I have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.Yes*
Informed Consent For Care Form
Doctors of Chiropractic, Medical Doctors, Doctors of Osteopathy and Physical Therapists who perform manipulation are required by law to obtain your informed consent before beginning treatment. I do hereby give my consent to the performance of conservative non-invasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues, in addition to active rehabilitation exercises. Although spinal manipulation is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows: Soreness: I am aware that, like exercise, it is common to experience muscle soreness in the first few treatments. Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. I realize this possible side effect and will note any such symptoms to my treating doctor. Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like bone weakening from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution. Stroke: Although strokes happen with some frequency in our world, strokes from spinal manipulation are exceedingly rare. I am aware that nerve or brain damage including stroke is reported to occur once in one million to once in ten million treatments and that the doctors of Designed 2 Move take extra precautions to appropriately rule out patients with potential risk. Bruising: It is understood that bruising, swelling, soreness and/or pain for 72 hours post- treatment is not uncommon after use of instrumented assisted soft tissue techniques and manual soft tissue release techniques.Exams have been/will be performed on me to minimize the risk of any complication from treatment and I freely assume these risks. Treatment Results I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function and reduced muscle spasm. However, I appreciate that there is no certainty that I will achieve these benefits. Due to the uniqueness of each disease and each individual, including his or her willingness and ability to implement the treatment plan, I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other persons the doctor sees fit. Alternative Treatment Options Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over-the-counter medications, exercises and possible surgery. Medications/Supplements: Medication can be used to reduce pain or inflammation but I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, produce undesirable side effects, create physical or psychological dependence and may have to be continued indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Certain exercises may be helpful in the healing process but direction/consultation should be sought to avoid further injury. Surgery: Surgery may be necessary for joint stability or serious disc rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia and prolonged recovery. Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy. Important Treatment InformationThe Doctors of Designed 2 Move Spine & Sport are not available on a 24-hour basis. If you have a serious health condition that requires immediate attention, you should dial 911, call your other available healthcare provider(s), and/or have someone transport you to the nearest emergency room. If you notice an adverse effect from one of the components of your health plan, you should discontinue it and call Designed 2 Move to inform the physician(s) of what has occurred.If you are being treated by other healthcare providers (physicians, counselors, therapists, etc.) please inform your physicians at Designed 2 Move. Do not discontinue any medications without consulting with your prescribing physician.To attest to my consent to these procedures, I hereby affix my signature on this form and give authorization for treatment. I have read or have had read to me and understand the above explanation of treatment to be received at Designed 2 Move Spine & Sport. Any questions I have had regarding these procedures have been answered to my satisfaction prior to my signing this consent form.I do hereby give my consent.Yes*
HIPPA Notice Of Privacy Practices Form
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law. “Protected Health Information” is information about you, including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related care services. Use and Disclosures of Protected Health InformationYour protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, pay your health care bills, to support the operations of the physician’s practice and any other use required by law. TreatmentWe will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your health care information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. PaymentYour protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare OperationsWe may disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing, fundraising activities and conduction or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.We may use or disclose your protected health information in the following situations without your authorization. These situations included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors and organ donation. Required uses and disclosures under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW.You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.I do hereby consent.Yes*