Schwenn Family Chiropractic

I understand that ALL visits will be filed with my insurance company. Any 1st visit coupons/gift certificates or promotions will be deducted from my patient balance. I understand and agree that Health and Accident insurance policies are an arrangement between my insurance carrier and myself. 

*****Please bring allow the front desk to make a copy of your Insurance Card for verification****

Our policy requires payment in full for all services rendered at the time of service.

I understand and agree that regardless of third party liability (insurance of any kind) I am ultimately financially responsible for all charges incurred on my account. I further undertand and agree that if my account is not paid within 90 days from the date of service (and other payment arrangements have not been made) the assistance of a collection agency will be enlisted and I will be responsible for any expenses incurred in collecting my account. 

By my signature, I agree to the statements above and that all information given is complete and accurate to the best of my knowledge. I understand that all information given is completely confidential.

Welcome to Schwenn Family Chiropractic. Please complete the following review of your bodily systems. While these conditions may not seem directly related to the reason you are here, this information will help the doctor get a better idea of your overall health past and present. Please check any conditions that you have presently or have had in the past.

Pregnancy History:

Menstrual History: 

This is to verify to the best of my knowledge I am NOT pregnant. I give Schwenn Family Chiropractic permission to perform an X-ray evaluation if it is clinically beneficial to my care. I have been advised against having an X-ray evaluation if there is any chance that I may be pregnant.

Please mark areas of pain on the drawing:

The above information is complete and accurate to the best of my knowledge.

The patient identified above authorizes Schwenn Family Chiropractic to use and/or disclose protected health information in accordance with the following specific authorizations:

• I give permission to Schwenn Family Chiropractic to use my address, phone number and clinical records to contact me with birthday cards, newsletters, new patient letters, thank-you cards, first adjustment calls, testimonials and information about treatment alternatives or other health-related information.
• I give Schwenn Family Chiropractic permission to treat me in an open room where other patients are also being treated.  I am aware that other persons in the office may overhear some of my protected health information during the course of care.  Should I need to speak with doctor at any time in private, the doctor will provide a room for these conversations.
• By signing this form you are giving Schwenn Family Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent;
• The right to object to the use of my health information for directory purposes; and
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. You have the right , as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives.

CHIROPRACTIC is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect the restoration and preservation of health. HEALTH is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

One disturbance to the nervous system is called VERTEBRAL SUBLUXATION. This occurs when one or more of the 24 vertebrae in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.

Subluxations are corrected and/or reduced by an ADJUSTMENT. An adjustment is the specific application of forces to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary procedures such as physiotherapy and/or rehabilitative procedures may be included.

If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider.

All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits, risks, and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis.

I, being the parent or legal guardian, have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care.