Self Pay Intake

Informed Consent to Chiropractic Treatment

We are committed to providing you with the highest level of care. Please review the following information carefully and ask any questions you may have.

Nature of Chiropractic Treatment

Chiropractic care involves adjusting your joints using hands or a mechanical device. You may feel or hear a "click" or "pop" similar to cracking a knuckle. Treatment may also include:
-Manual therapy, electric muscle stimulation, traction, and guided exercises.

Authorization of Care

I authorize the doctor to perform spinal adjustments and rehabilitative exercises to restore normal function.

I understand that:
-I am responsible for all fees incurred.
-The doctor is not responsible for pre-existing conditions or diagnoses made by other providers.

Risks of Not Receiving Treatment

Delaying treatment may lead to adhesions, scar tissue, reduced mobility, and chronic pain. If I terminate care early or do not follow recommendations, I understand that I may not receive the full benefi ts of treatment, and all outstanding fees will be due.

I authorize the assignment of all insurance benefi ts directly to the doctor for services rendered.

Consent to Treatment

I have read and understand the information provided. I have had the opportunity to ask questions and voluntarily consent to chiropractic care.

HIPAA Guidelines

We protect your privacy in compliance with HIPAA regulations. Your health information (PHI) may be disclosed for:
-Referrals, billing, and internal quality control.
-Appointment reminders, thank you notes, and promotional information. You have the right to: -Request restrictions on how your PHI is used (in writing).
​​​​​​​-Revoke consent at any time (in writing).
-Review our full privacy notice upon request.

Acknowledgement: I have read and agree to the terms of this consent policy. I acknowledge that I have received a copy of this notice if requested.

Office Policies

To ensure a smooth and efficient experience, please review and sign our office policies:
1. Late Policy We will hold your appointment for 15 minutes. If you are more than 15 minutes late and have not called or texted to reschedule, your appointment will be considered a no-show .

2. No-Show Policy We understand that things come up, but if you miss a scheduled appointment without reaching out to reschedule, a $50 no-show fee will be charged to the card on file. If a patient has three no-shows, we may need to reconsider future scheduling options, as it’s important that we maintain availability for all of our patients. We want to ensure that each patient receives the care they need, and we appreciate your understanding and cooperation.

3. Cancellation Policy We require at least 24 hours’ notice for appointment cancellations. If zero attempt is made the reschedule and the appointment is a no-show a fee may apply for late cancellations or missed appointments.

4. Scheduling Policy
● We recommend scheduling follow-up visits in advance to maintain your treatment plan and ensure availability.
● Appointments are also available for booking through Zocdoc.

5. Payment Policy
● Payment is due at the time of service unless other arrangements have been made.
● All patients are required to keep a card on file for payment and convenience purposes. We accept cash, credit cards, and checks.
● Any outstanding balances must be resolved promptly. We can charge the card on file for convenience if needed.

6. Insurance Policy
● We will assist with the initial contact to verify your insurance coverage; however, it is ultimately your responsibility to confirm coverage and benefits.

● If your insurance changes or coverage is inactive for any reason, any unpaid balance determined by your insurance as patient responsibility will become your responsibility.

Consent to Office Policies

I have read and understand the office policies outlined above. I agree to comply with these terms and accept responsibility for any applicable fees or charges.