• PATIENT INTAKE FORM

    PATIENT INTAKE FORM

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  • FINANCIAL POLICY & INSURANCE INFORMATION

  • Clinic fees:

    Adults: 

    Initail Consultation/Exam/Spinal Screening                          $100.00

    Office Visit, chiropractic, laser KST                                         $65.00

     Re-examinations                                                                   $100.00

    Extended Visits: 

    Chiropratic with accpunctre, laser, KST                                                  $100.00

    Child/Student:

     

    Initail Consultation/Exam/Spinal Screening                        $50.00

    Office Visit, chiropractic, laser KST                                     $50.00

    Re-examinations                                                                 $50.00

    Extended Visits:

                 Chiropratic with accpunctre, laser, KST                                     $60.00

  • I clearly understand and agree that all services to me are charged directly to me and that I am personally responsible for the payment. I also understand that if I suspend or terminate my care and treatment, any fee for professional services to me will be immediately due and payable.

  • Clear
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  • I am the parent and/or guardian of this child and provide consent for this child's treatment.

  • Clear
  • Consent to Chiropractic Treatment

    It is important to consider the benefits, risks and alternatives to treatment. This will help you make an informed decisionabout proceeding with care.Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body. Italso includes soft-tissue techniques, therapeutic modalities and exercise.

    Benefits - Chiropractic treatment has been shown to be effective for complaints of the neck, back and other areas ofthe body related to nerves, muscles and joints. Treatment by your chiropractor can relieve pain, including headache,altered sensation, muscle stiffness and spasm. It can also increase mobility and improve function.

    Risks - The risks associated with chiropractic treatment vary according to each patient’s condition and the location andtype of treatment. The risks include:

    ● Temporary discomfort or worsening of symptoms – Treatment may cause some discomfort or an increase inpre-existing symptoms of pain or stiffness. This can last a few hours to a few days.

    ● Skin irritation or burn – Skin irritation or a burn may occur with the use of some types of electrical and lighttherapies. Skin irritation should resolve. A burn may leave a permanent scar.

    ● Sprain or strain – A muscle or ligament sprain or strain may occur. These should resolve within a few days orweeks with rest, minor care and/or protection of the affected area.

    ● Rib fracture – A rib fracture may occur. This can be painful and limit your activity for some time. These usuallyheal over several weeks with or without further treatment.

    ● Disc injury or aggravation – Some reported cases associate chiropractic treatment with injury or aggravation ofa disc condition. This is rare. Spinal discs may degenerate with age or become damaged, with or withoutsymptoms. Signs and symptoms may include neck and back pain, impaired mobility, or radiating pain andnumbness into the legs or arms. In severe cases, impaired bowel or bladder function or impaired leg or armfunction may occur, which may need surgery.

    ● Stroke – Some reported cases associate chiropractic treatment of the neck with stroke. This is rare. This type ofstroke is a serious event involving arteries in the neck and the interruption of blood flow to the brain. Theconsequences of a stroke can include impairment of vision, speech, balance and brain function, as well asparalysis or death. If signs of stroke occur, seek medical attention immediately.

    Alternatives - Alternatives to chiropractic treatment may include consulting other health professionals, over-the-counter pain relievers, rest, and exercise. Each may have their own benefits and risks.

    Questions or concerns - Please ask questions at any time about your assessment and treatment. Bring any concernsyou have to the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time. You areencouraged to be involved in and responsible for your care. Inform your chiropractor immediately of any change in yourhealth or condition.

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