Freedlund Family Chiropractic 506 North Elida Street Winnebago, IL 61088 (815) 335-1381 Patient Consent For use and/or disclosure of Protected Health Information (PHI) To carry out Treatment, Payment, and Healthcare Operations I hereby states that by signing this Consent, I acknowledge and agree as follows: The Practice's Privacy Notice has been made available to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (PHI) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. The Practice's "Notice of Privacy Practices" is also provided upon request. I may also request a copy from this office at any time via US Mail. This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health information. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my home and leaving a message on my answering machine , with the individual answering the phone, or sending texts or emails. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or health care operations. However, the Practice is not required to agree to any restriction that I have requested. If the practice agrees to a requested restriction, then the restriction is binding on the Practice. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent. I understand that if I do not sign this consent or revoke consent at any time, the Practice has the right to refuse to treat me. I understand and consent to the following other types of correspondence from this office: A) birthday card may be texted or emailed to me at the address I provided; and B) I may receive periodic mailings of general health information in the form of a newsletter, email, or text. CHIROPRACTIC INFORMED CONSENT TO TREAT I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and like all other health modalities, results are not guaranteed, and there is no promise of cure. I further understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited to, self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and to secure other opinions if I have concerns as to the nature of my symptoms and treatment options. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. ** For Minors**I authorize the doctors at Freedlund Family Chiropractic to treat my son/daughter. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. Nutritional Informed Consent: A Vitamin is not a drug. Neither is a Mineral, Trace Element, Amino Acid or Herb. Although a Vitamin, Mineral, Trace Element, Amino Acid or Herb may have an effect on any disease process or symptom, this does not mean that it can be misrepresented or be classified as a drug or that recommended supplements are a treatment for said condition. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the patient’s diet in order to supply good nutrition by supporting the physiological and bio-mechanical processes of the human body. I understand that nutrition recommendations are not a treatment of any disease or other medical conditions and that nutritional or dietary programs are not guaranteed and no promises have been made regarding them. I have READ and UNDERSTAND the foregoing and this permission form also applies to subsequent visits and consultations.