Please check all sympotms that apply to you.

Payment for treatment: You agree to pay by cash, check ,or credit card on the day that treatment is rendered. Unless we approve other arrangements in writing, the balance on your account is due and payable when the services are rendered, and is past due if not paid by this time.

Insurance: If applicable, I hereby authorize my health insurance company or claims administrator (personal injury/car accident) to pay by check, and for it to be made directly to LiveSmart Chiropractic & Rehabilitation the expenses benefits allowable and otherwise payable to me under my current policy as payment toward the total charges or professional services rendered. I have agreed to pay in a current manner, any balance of said applicable charges. I agree that this office by given power of attorney to endorse/sign my name on any and all drafts for payment of my bill. Full payment is expected at the time of service unless prior arrangements have been made. It is the policy of this office that all services rendered are charged directly to you, the patient, and that ultimately the patient is responsible for all services, including those not reimbursed by third party payors. All insurance assignment patients must pay their deductibles in full and the co-payment at the time of service, or at the end of each week.

Missed Appointment Fees: Patients who do not show up for an appointment or cancel with less than 48 hours notice will be charged a the total cost of the visit unless otherwise stated by the provider . This fee must be paid before a new appointment is scheduled, and will be charged to the patient’s payment account on file. Providing updates to any and all contact information are the sole responsibility of the patient.

Credit History: We may report your account status to any credit-reporting agency such as a credit bureau for delinquent accounts. If your accounts become past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs, which are incurred. If we have to refer collection of balance to a lawyer, you agree to pay all lawyers’ fees, which we incur, plus all court costs.

Returned Checks: There is a fee (currently $25) for any checks returned by the bank.

Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your
past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Transferring of Records: You understand that you will need to request in writing, and pay a reasonable copying fee (currently $25) if you want to have a printed copy of your patient health record.

I certify to the best of my knowledge, the above information is complete and accurate. If using a health insurance plan and the information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future.

I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.

Insurance Disclaimer: “A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms,
conditions, limitations, and exclusions of the member’s contract at time of service.”

Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Every effort will be made by this office to have all services and procedures authorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. If my health insurance company denies payment,

I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be
responsible for any co-payment, deductible, or coinsurance that applies. Although rare, insurance companies may provide us with incorrect information about your health plan. Thus, I understand that it is ultimately my responsibility to verify my chiropractic insurance benefits.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding

and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures, if indicated. Any examinations or tests conducted will be carefully performed, but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including, but not limited to, hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people, whether they are receiving health care or not. Patients who experience this condition often, but not

always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The

association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent & office policies. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance.

I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.