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Dr John Surie: New Patient Intake Fore

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    ARRIVAL DETAILS:

    Address: 117 Ashmore Road, Bundall, QLD 4217 

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    My office is located inside FIRE SHAPER hot yoga.

    Please enter into Fire Shaper and proceed up the stairs (just past the desk)

    Once you are upstairs my office is directly in front of you.

    Please take a seat and I'll be right with you.

     

    note: There is a chiropractor downstairs as well which is not my space. If you happen to go in there by accident make sure you smile and say hello :) then proceed upstairs.

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      All information is held strictest confidence. At no given point is information disclosed or shared without our client’s written consent. 

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    If you are completing this form for your child please put their name here and complete the remaining portions of the form with the CHILD'S information. (click NEXT if not applicable)
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    This should be the contact number of the adult completing this form.
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    This should be the email of the adult completing this form.
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    This can be anything and does not have to be pain oriented or problem oriented
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    • 1 - very little
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    • 10 - very painful
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    By example: Natural, C-section, use of suction/forceps, emergency...
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    I'd like to know if there are other things that you chronically experience even though they may be totally un-related.
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    If yes, please explain. If none, leave blank and click NEXT
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    READ ONLY - THEN click NEXT

    1. I have had the opportunity to discuss the proposed care with Dr John Surie. I also acknowledge that I have had the opportunity to ask questions about the nature, extent and purpose of the proposed chiropractic care and that I have been given sufficient time to make a decision giving consent for the care to proceed.

    2. I acknowledge that I am aware of and understand the potential risks. I appreciate that results are not guaranteed.

    3. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.

    4. I hereby acknowledge my consent to the performance of the proposed chiropractic care by Dr John Surie and/or any other chiropractor working in this clinic. I understand that I can withdraw consent at any time.

    5. I give this clinic permission to use my postal address to send me birthday cards and thank you cards. I also give permission for my photographs to displayed in this clinic and / or online for the purposes of social sharing and education.

    6. In very rare circumstances, some treatments of the neck may damage a blood vessel and lead to stroke or related symptoms (current statistics eg between 1 in 2 million to 1 in 5.85 million -Haldeman, et al. Spine vol 24-8 1999). Other possible risks include strain/injury to a ligament or a disc in the neck (current statistics eg less than 1 in 139,000) and the low back (current statistics eg 1 in 62,000 Dvorak study in Principles & Practice of Chiropractic, Haldeman 2nd Ed.). For some patients especially with bone weakening diseases, a fracture of a bone although rare is possible.”

    7. I acknowledge that I have discussed with Dr John Surie the rare risks associated with my proposed care which include but are not limited to muscle and joint soreness or strains, nausea and dizziness, fractures, disc injuries including disc encroachments/ruptures, causing nerve irritation and referred symptoms, strokes (or like episodes) and an exacerbation and/or aggravation of my underlying condition. Such risks may result in outcomes such as referral, further tests, surgery, incapacity and the like.35591

     

    Dr John Surie

    Doctor of Chiropractic

    Provider Number: 5035591H

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    By clicking YES you are stating that you have read the consent agreement and that you would like to continue onward to being treated by Dr John Surie and that you are providing your agreeable consent for that ongoing treatment.
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    This is the patient or in the case of a minor (17 & under) this would then be the parent or guardian that is over 18 yrs of age.
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    This should be the adults signature or in the case of a minor this should be the parent or guardian.
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