PLEASE READ CAREFULLY BEFORE SIGNING
TREATMENT CONSENT, RISKS & ACKNOWLEDGEMENT
01 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, on me (or on the patient named below, for whom I am legally responsible) by a KCS doctor of chiropractic.
02 I have had an opportunity to discuss with the doctor of chiropractic and/or other clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed.
03 I understand and am informed that, as in the practice of medicine, there are risks associated with chiropractic treatment, including but not limited to fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of treatment based upon the facts then known and what the doctor believes is in my best interests.
04 I have read, or have had read to me, the above consent and have had an opportunity to ask questions about its content. By signing below, I agree to the above-named procedures and intend this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.
PATIENT RESPONSIBILITIES
05 I understand that I am responsible for providing accurate health information, informing the clinic of changes that may affect treatment, following treatment instructions, and attending scheduled appointments or notifying the clinic when I need to cancel or reschedule.
06 I understand that eligibility for ongoing KCS primary care, specialty services, and internal referrals may depend on having KCS assigned as my Managed Medi-Cal Primary Care Provider (PCP).
ATTENDANCE, LATE ARRIVAL & CANCELLATION POLICY
07 Late Arrival: I understand that if I arrive 10–20 minutes late for my scheduled appointment and still wish to receive treatment, I may receive treatment for the remaining scheduled appointment time. I understand and agree that my treatment time will be shortened and the appointment will not be extended.
08 Cancellation/Rescheduling: I understand that I am required to provide at least 24 hours advance notice when cancelling or rescheduling an appointment. Cancellations made with less than 24 hours notice or missed appointments (no-shows) will be subject to the clinic’s cancellation and attendance policy.
09 Repeated No-Shows: I understand that 3 consecutive no-shows or 3 no-shows within a 6-month period will result in a formal written notice and may lead to a temporary suspension of routine CAM treatment scheduling for 3 or 6 months, rather than immediate termination, in accordance with clinic policy.
ARBITRATION
Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decide in court of law before jury and instead are accepting the use of arbitration. Further the parties will not have the right to participate as a member of any class of claimants, and there shall no authority for any dispute to be decided on a class action basis. Any arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims. By signing this contract, I am agreeing to have any issue of medical malpractice decided by neutral arbitration, and I am giving up my right to jury or court trial. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of chiropractic and other procedures, and have had an opportunity to ask questions. 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.
I intend this consent to apply to all my present and future chiropractic treatment.