TERMS OF ACCEPTANCE POLICY - When a patient seeks chiropractic and/or acupuncture health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. 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 of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we 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. Our only method is specific adjusting to correct vertebral subluxation. No Cell Phones or Other Recording Devices: No recording devices are allowed in this clinic with the exception of the waiting room area (this exception does not include changing rooms.) Any no call and/ or no show appointments are considered a used appointment and will be counted as such for ALL care plans, valued at $70 per visit. All care plans expire year from signed date. Nutritional Supplementation/Counseling: I understand that the purpose of nutritional protocol is to provide special food concentrates for dietary purposes. I understand that the nutritional protocols are not intended to diagnose or cure any disease. Full Circle Health’s policy is that nutritional supplements are not refundable or exchangeable due to the maintenance of quality control of our inventory. Risk: Chiropractic – like any other therapeutic programs in healthcare is not without its risks. Chiropractic adjustments, acupuncture, nutritional recommendations and exercise programs applied may result in serious injury or death. Financial Responsibility/Insurance: I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I understand and agree that all services rendered to me will be charged to me, and I’m responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself not Full Circle Health. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office about any possible violations of these policies and procedures. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, our office has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. X-Ray Release - this is to certify that the doctors of Full Circle Health have my permission to perform an X-ray evaluation and the x-rays are property of Full Circle Health. To the best of my knowledge I am not pregnant and I have been advised that x-ray can be hazardous to an unborn child. Consent to Care for Minor -(only required if patient is under 18 years of age & only individual with legal custody over the minor can confirm care) I authorize Full Circle Health and whomever they may designate as her assistant to administer care as she so deeds necessary to my son/daughter. I certify that I’m the patient or legal guardian listed above. Accurate Information Acknowledgement- I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. I authorize the doctor or her staff to render care as deemed appropriate for me and/or my child. I authorize Full Circle Health to release and/or request records to or from other providers as may be necessary. I authorize Full Circle Health to use my name, testimony, or photo during the normal course of business. I understand I am responsible for all bills incurred in this office. I have read, understand, and agree to Full Circle Health's terms of acceptance policy. I understand that after any initial promotional services, all care is rendered at usual and customary fees.