TERMS OF ACCEPTANCE
When a person seeks chiropractic and rehabilitation health care and is accepted for such care, it is essential for both parties to be working towards the same objective. As a Chiropractic and Rehab facility we have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment.
- Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine.
- Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.
- Vertebral Subluxation: A misalignment of one or ore of the 24 vertebra in the spinal column which causes alteration of nerve function and intergerence to the transmission of mental impluses, resulting in a lessening of the body's innate abilty to epress it's maximum health potential.
We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Also, we do not offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body's innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations combined with rehabilitation procedures.
CONSENT TO CARE
I do hereby authorize the doctors of Central Chiropractic to administer such care that is necessary for my particular case. This care my include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy or any other procedure that is advisable, and necessary for my health care.
Furthermore, I authorize and agree to allow the doctor of chiropractic named below and/or licensed doctors of chiopractic who now or in the future treat me while employed by, working for, associated with or serving as back-up for the doctor of chiopractic named below, including those working at the clinic or office listed below or any other office or clinic, to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function.
I have had an opportunity to discuss with the doctor of chiopractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all cahrges. I further understand that a fee for services rendered will be charged and that I am responsible fo rthis fee whether results are obtained or not.
I understand and was 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, disk 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 whch the doctor feels at the time, based upon the facts then known, is in my best interests. The doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions treated at this clinic.
I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assigment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor.
I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, 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.
Treating Chiropractor: James W. Smith, DC