Patient Intake Form

We are committed to protecting the privacy of your personal information. The purpose of this notice is to inform you of the types of personal information we obtain and how we protect that information.

What is personal information?

We treat any information that is identifiable to you as your personal information, whether or not it may be otherwise available to the public. We collect personal information related to your:

• health condition, including health care diagnosis, treatment, and payment
• identity, such as your name, age, or address

Why do we collect your personal information?
We collect personal information from you to help:

• diagnose and provide appropriate treatment for you
• submit insurance claims if needed
• provide billing services for you

How do we collect your personal information?
We collect your personal information only through you, another health care provider when requested and signed by you, your insurance company as it pertains to processing your claim and through your transactions with us.

To whom do we disclose your personal information?
We will not disclose your personal information unless we are allowed or required by law to make the disclosure, or if you give us permission. The following are some examples of disclosures we may make as allowed or required by law:

• To insurance companies (only after we have received a signed consent from you releasing that information and only as in pertains to an insurance transaction).  
• To another health care provider (only after we have received a signed consent from you releasing that information and only as it pertains to the health history requested).
• To respond to legal requests such as a subpoena.

We will not disclose your personal information to any company for that company’s marketing purposes.

How do we protect your personal information?

We protect your personal information by:

• Treating all of your personal information that we collect as confidential
• Stating confidentially policies and practices, as well as disciplinary measures for privacy violations, in our employee policies and procedures handbook
• Restricting access to your personal information to only those employees who need to know your personal information in order to provide services to you
• Disclosing only your personal information that is necessary for a service company to perform its function on our behalf, and only when the company agrees to protect and maintain the confidentiality of your personal information
• Maintaining physical, electronic, and procedural safeguards that comply with federal and state regulations to guard your personal information
   

I have read and understand Dr. Giles’ Privacy Policy. I also understand that all information received through Dr. Giles’ office is confidential and will not be released without a signed consent.

1. Payment is required at the time of service.  For your convenience we accept cash, checks, Visa, MasterCard, and Discover Card; also, Apple, Samsung, and Google Pay. We do not accept American Express.  All supplements/merchandise must be paid for on the day they are received/ordered.
2. All missed appointments and those canceled within 24 hours will be charged the full amount of the scheduled visit. More than three no-shows will result in dismissal as a patient.
3. A $15 fee will be charged to patients whose checks are returned unpaid by their bank. As a courtesy, we will process your check once more before being referred to collections. 
4. Please be aware that Dr. Giles is not a contracted provider for any insurance company except Medicare. However, we can provide a detailed receipt with all billing codes and information needed for you to submit to your insurance company for reimbursement by you. Accounts which are 60 days past due will be subject to interest charges, and accounts 90 days past due will be forwarded for collection.
5. Special information for Auto Accidents: Utah Personal Injury Protection Benefits include a minimum of $3,000 for patient care.  Once this limit is reached, patients will be required to pay for all services at the time they are rendered.  It is the patient’s responsibility to fill out and return their PIP benefits application to their insurance company in a timely manner.  Your insurance company will not pay on claims until this application has been received.  We suggest you provide a copy of the completed application to our office to help expedite payment.  Since we are unaware of other health services you may have received, we cannot be responsible to keep track of your PIP balance/benefits.

I have read and understand the above terms and conditions. I hereby assign benefits directly to this office for professional services rendered and I shall be personally responsible for any unpaid balance to the doctor. In the event of a past due balance, I understand that interest will be charged at 18% per annum.  I understand if collection action becomes necessary, I will be responsible for all collection fees, costs, and reasonable attorney’s fees.

Disclosure & Consent to Treat For

Chiropractic and Other Medical or Alternative Services

TO THE PATIENT: You have the right as a patient to be informed about your condition and the recommended chiropractic adjustments and other procedures to be used so that you may make the decision whether or not to undergo the recommended procedure(s) after knowing the potential risks and hazards involved. This is intended to make you better informed so you may give or withhold your consent to the procedure(s)/treatment(s).

 I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, alternative therapies, and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by Troy Giles, D.C. and/or other licensed Doctors of Chiropractic substituting for Dr. Giles, massage therapists, or those working at the clinic or office who now or in the future treat me. I have had the opportunity to discuss with Dr. Giles, my diagnosis, the nature and purpose of Chiropractic adjustments and other procedures and alternatives. I understand and I am informed that, in the practice of chiropractic, there are some risks to examination and treatment including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains and increased symptoms and pain or no improvement of symptoms or pain, and I hold harmless Troy D. Giles, the clinic, employees of the clinic, Bountiful Family Wellness Center, and Troy Giles, D.C., Inc. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure(s)/treatment(s) which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I understand that the examination notes, treatment notes, and x-ray films will remain the property of BFWC. Copies may be requested for a nominal copying charge.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan recommended by Dr. Giles. 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.

To be completed by the patient

To be completed by the patient’s representative, if necessary, e.g., if the patient is a minor or physically or legally incapacitated:

For the purpose of specific treatment for

I understand that there are no guarantees as to the outcome of these treatments and that they are not regulated by the FDA. I do not expect Dr. Giles to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the treatment and based on the facts then known, to proceed with what is in my best interest and agree to hold harmless: Troy D. Giles, his employees, Bountiful Family Wellness Center, Troy Giles, D.C., Inc., the clinic, and any relief doctor substituting for Dr. Giles. I have been informed that risks and complications of venipuncture and Platelet Rich Plasma (PRP) injection and therapy, although extremely rare, can be, but are not limited to: pain at the venipuncture / injection site, allergic reactions, infection at the injection site, damage to local structures including injury to nerves and muscles, numbness, bruising, hematoma, and blood clotting.

I have been informed that risks and complications of injection and/or acupuncture therapies, although extremely rare, can be, but are not limited to: pain at the injection site, allergic reactions, infection at the injection site, injury to nerves and muscles at the injection site or numbness. The injection(s) may include agents used in an “off-label” manner. This essentially means that the physician can legally choose to administer homeopathic(s) in a manner that is not specifically noted on the package insert, so long as the patient has been fully informed and consented.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan recommended. 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.

To be completed by the patient:

To be completed by the patient’s representative, if necessary, e.g., if the patient is a minor or physically or legally incapacitated: