Please identify the condition(s) that brought you to this office:

On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by entering a number below for each complaint.

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

I hereby authorize payment to be made directly to Southern Family Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Southern Family Chiropractic for any and all services I receive at this office.

REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures:

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint function, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravated and/or temporary increase in symptoms, lack of improvement to symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains and sprains. With respects to strokes, there is a rare but serious condition known as “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving and playing tennis.

Arterial dissections occur 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their doctor or chiropractic with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. The reported association attributed between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in a million to one in two million cervical adjustments. For comparison, the incidence of hospital admissions attributed to aspirin use for major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.

It is important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about my consent, and by signing below, I agree with the current or future recommendations to receive chiropractic care as is deemed appropriate for my circumstances. I intend this consent to cover the entire course of care from all health care providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

REGARDING: X-rays/Imaging Studies

As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays from our files. The fee for copying your x-rays on a disc is $15.00. This fee must be paid in advance. The digital x-rays on a CD will be available 48 hours after prepayment.

Please note: X-rays are utilized in the office to help locate and analyze vertebral subluxations. These x-rays are not to be used to investigate for medical pathology. The doctors of Southern Family Chiropractic do not diagnose or treat medical conditions; however, if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice.

By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

FEMALES ONLY: please read carefully, include the appropriate date, then sign below if you understand and have no further questions. Otherwise, please see our receptionist for further explanation.

I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my(knowledge, I am NOT pregnant. (sign below)

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information (PHI In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

1. Treatment purposes - discussion with other health care providers involved in your care. 2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room. 3. For payment purposes - to obtain payment from your insurance company or any other collateral source. 4. For workers compensation purposes - to process a claim or aid in investigation. 5. Emergency - in the event of a medical emergency we may notify a family member. 6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public. 7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person. 8. For military, national security, prisoner and government benefits purposes. 9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death. 10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events. 11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

1. To receive an accounting of disclosures. 2. To receive a paper copy of the comprehensive “Detail” Privacy Notice. 3. To request mailings to an address different than residence. 4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction. 5. To inspect your records and receive one copy of your records at no charge, with notice in advance. 6. To request amendments to information. However, like restrictions, we are not required to agree to them. 7. To obtain one copy of your records at no charge, when timely notice is provided (72 hoursX-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

If you wish to make a formal complaint about how we handle your health information, please call Dr. Tyler Gravley at (504) 462- 0242. If he is unavailable, you may make an appointment with our receptionist to see him within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building Washington DC 20201

SOUTHERN FAMILY CHIROPRACTIC NOTICE REGARDING YOUR RIGHT TO PRIVACY continued

I have received a copy of Southern Family Chiropractic Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.

Medical Information Release Form

(HIPAA Release Form)