Informed Consent

Risk factors

Doctors of Chiropractic (DC), MD, and DPT who use manual therapies such as spinal or extremity adjustments and/or therapies are required to advise patients that there may be some risk associated with such treatment. In particular, you should know that:

· While very rare, reports of fracture to bone, disk injuries, damage to muscles or ligaments have occurred following adjustments. In most of these cases, osteoporosis and/or serious degenerative diseases are a factor. Please inform your doctor of these conditions prior to any treatments.

· While extremely rare, reported cases of stroke following a cervical adjustment have been noted. However, the possibility of a cervical-related stroke has been estimated to occur in one in every million to five million adjustments.

You have choices. You may choose to receive the medical model of care, which could include drug therapy or surgery. Other therapists may be able to perform similar treatment protocols as well. The risk of such may be more, less, or equal to chiropractic.

Your treatment is designed to provide the optimal conditions for restoring and maintaining good health. The duration of treatment and therapy is based on the nature of the problem. Treatment duration is only an approximation of time or a number of treatments based upon similar instances or the opinion of the doctor. This does not guarantee an outcome, nor is it a contract of any kind.

I acknowledge I have discussed or had the opportunity to discuss the nature of the information presented and therefore consent to chiropractic examination, adjusting, and therapy.

Authorization to Release Medical Information

I authorize Dr. Mark E. Lee, DC, Lee Family Chiropractic/Chiro Health, and/or its staff to release my personal healthcare information necessary to receive payment for services to any or all parties associated with me and my healthcare treatment. I will not and do not hold Dr. Mark E. Lee, DC or anyone associated with his clinic personally liable for the release of this information when deemed necessary to do so.

Financial Responsibility and Payment Policy

Payment is due at the time of service. Any financial arrangements must be made at the first visit. This clinic does not customarily reduce or adjust balances owed. Every effort will be made to collect from your auto insurance companies; however, you are responsible for the balance due. We will also work with an attorney regarding personal injury claims, including waiting for the settlement before being paid. (Medical payment benefits are billed, and payment is expected upon receipt of reimbursement.)  Acceptable forms of payment include cash, credit cards, debit cards, and Health Savings Accounts (HSA). Pre-Paid Wellness Plans are available to all patients. I authorize payment in full to Dr. Mark E. Lee, D.C., and Lee Family Chiropractic/Chiro Health for all services rendered. I direct my insurer or any entity involved to take no reductions or adjustments without prior written authorization from Dr. Mark E. Lee, D.C.

Appointment Agreement

We understand schedules can change, and unforeseen circumstances can arise. We offer a confirmation system that allows you to confirm or reschedule your appointments via text message. To ensure we can accommodate all our valued patients, we kindly request adherence to our cancellation policy.

1. Cancellation Notice:
Clients must notify us of cancellations or appointment changes at least 24 hours in advance. Please call us at 480-644-0644 during business hours to cancel or reschedule. You can also text us at 480-500-9931 24/7.

2. Late Cancellations:
Cancellations made within 24 hours of the appointment will incur a $25 charge.

3. No-shows:
Failing to show up at your scheduled appointment without prior notification will incur a $60 charge. Repeat no-shows may result in having to prepay for future services or prevent you from booking future appointments.

4. Late Arrivals:
We understand delays can happen. However, clients arriving more than 15 minutes late may be asked to reschedule. This ensures we can give you and our other patients the time and attention you deserve.

5. Exceptions:
We recognize that emergencies and special circumstances can occur. Exceptions to our policy are made on a case-by-case basis at the discretion of Dr Lee and his office staff.

Contacting Us:
If you have any questions about this policy or would like to make any changes to your appointment, please call us at 480-644-0644 or text us at 480-500-9931.

By booking an appointment, you acknowledge and agree to our cancellation policy. This policy allows us to manage our schedule and ensure everyone receives the time and attention they deserve.

We appreciate your understanding and cooperation.
Thank you for choosing Dr Lee’s Chiro Health.