drjasonwhite.com - Terms of Acceptance

TERMS OF ACCEPTANCE
When a patient seeks chiropractic 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 and disappointment.

Adjustment: An adjustment is the specific application of force 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 disease or infirmities (aka symptoms).

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 it’s maximum health potential.

We do no 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 a non-chiropractic or unusual finding, we will recommend that you seek the services of a health care provider who specialized 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 PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our method is specific adjusting to correct vertebral subluxations.
I Name have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction and I accept chiropractic care on this basis.
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Initial Uses Authorization Form
InitialI understand I have a right to review Advanced Care Chiropractic's Notice of Privacy Practices prior to signing this document. Advanced Care Chiropractic's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Advanced Care Chiropractic. The Notice of Privacy Practices for Advanced Care Chiropractic is also provided upon request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Advanced Care Chiropractic's duties with respect to my protected health information.

Initial Advanced Care Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices at any time.

InitialAdvanced Care Chiropractic also uses limited protected health information for the following reasons: (You may opt out of this option) Marketing; internal boards, social media, testimonials, pictures on bulletin boards, or information unrelated to healthcare, etc.

By signing this form, you acknowledge that you were presented with a copy of our Notice of Privacy Practices. By supplying your home phone number, mobile phone number, email address, and any other personal contact information below, you are giving Advanced Care Chiropractic the authorization to use it for our newsletters and text messages to notify you of upcoming appointments/reminders/account balances/ Statements and any news/promotions from our office.
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TERMS OF ACCEPTANCE

Initial Uses Authorization Form