If no, please insert "At Fault Party" Insurance information below:

Please check mark all symptoms that have occurred since the accident:

DESCRIBE AREA OF COMPLAINT - Begin with the area causing the most distress. (circle the words that apply)

I will pay in full for services at the time of my appointment unless I have insurance coverage that requires another arrangement, or I make a different agreement with my provider.

Mv initials indicate that I have read and agree with each item below.

Any co-payment or co-insurance will be due in full at the time of service.

All initial appointment fees are due upon first day of service. Special financial arrangements must be discussed by the second appointment.

A $25 processing fee will be charged for any NSF fees on each return of payment.

A fee will be charged for missed appointments and cancelled appointments inside of 24 hours.

• $30 charge for 1 Hour massage
• $15 charge for 30 min massage
• $10 charge for Chiropractic Adjustment
• $10 charge for Laser
• $10 charge for Spinal Decompression

All payments will be processed to the credit card on file that same day. Late arrivals to sessions may require to be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for "full cost" of the cost of that session. Out of respect and consideration for your therapist and other customers, please plan accordingly and be on time.

I authorize the release of any medical information necessary to process my claim and/or for better treatment in this office including x-rays, MRIs, Lab tests, etc.

It is my responsibility to know what services are covered by my insurance plan. I have reviewed carefully the section in my insurance coverage booklet that describes the coverage of benefits for the services that will be provided at this office. I will call my plan administrator with any questions. I will pay for any services I receive that are not covered or denied by my insurance plan.

INFORMED CONSENT TO CHIROPRACTIC SERVICES

 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, dislocations, strains, and sprains. In addition, the literature recognizes an association between strokes
and chiropractic manipulation of the cervical spine. With respect to strokes, there is a rare but serious condition known as
an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a
thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that
chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders,
medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial
dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.
 Carotid and vertebral artery dissections are rare, with an annual incidence of 2.5 – 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.
 The reported association between visits to a chiropractor or a primary care physician and stroke is exceedingly rare and is
estimated to be related in one in one million to one in two million visits.
 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. 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.

Informed Consent to Massage Therapy Services           

 I hereby consent to massage therapy to be performed by affiliate Massage Therapist within the office and acknowledge that if I
experience any pain or discomfort within the massage session
 I have read, or have had read to me, the above consent. I consent to the opportunity to ask questions about its content, and by signing
below I agree to the above-named procedures. 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. I will immediately inform the therapist so that the pressure and/or strokes may
be adjusted to my level of comfort.
 I further understand that Massage Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and
that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.
 Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions,
and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that
there shall be no liability on the therapist’s part should I fail to do so.
 Cupping/Gua Sha: I understand that cupping therapy will leave bruise-like marks that will last several days depending on the severity of
my condition. While most marks fade and disappear after a few days, there are times when marks could take up to 15 days to clear and in
rare cases, it has been reported that marks have taken up to 21 days to fully clear.
o Contraindications: 1. Hemophilia or other bleeding/clotting disorders 2. Patients taking blood thinners 3. Weak patients or
those who have been ill 4. Abdomen and lower back on pregnant women 5. Diabetics. Especially those with uncontrolled
blood sugar as they may not be able to feel pain properly 6. Those who are unable to experience heat or pain properly 7. Those
who have circulatory conditions 8. Those who are unsure if their condition is contraindicated should seek guidance from their
primary care physician prior to receiving cupping therapy.
o I understand that bruising, discoloration and/or soreness will likely occur following this treatment and may take days or weeks to
fully resolve. I further understand that the above-listed conditions are contraindicated for cupping therapy and I have informed
my therapist/physician of any and all medical conditions, even those not listed as contraindications. I further understand that
there is a potential for burns and/or blisters due to the fire/heat aspect of the treatment. This is a rare but not unexpected
occurrence. 
 Improper Conduct: This is a Therapeutic Massage session and any sexual remarks or advances will terminate the session and understand I
will be liable for payment of the scheduled treatment. I understand the Massage Therapist practitioner reserves the right to refuse services
to me for any reason that the Therapist deems necessary. Male and female modest will be considered will not be exposed or touched at
any time. Professional draping will be used for your privacy and comfort. Our policy requires therapists to leave the room prior to
disrobing/undressing and use draping with sheets/ blankets at all times during every massage session.

Informed Consent to Class 4 Laser Services
Consent and Contraindications

Contraindications and Cautions
Use Laser Therapy with extra care if you meet any of the following criteria:
 Sensitivity to light
 Pregnancy
 Cancerous tissues or tumors
 Taking light sensitive medications or are pre-treated with photo sensitizers
 Are you are any medications that are heat sensitive? Yes or No
I have fully read and understand the provided information about Class 4 Laser Therapy and the
contraindications and cautions for treatment. I consent that I do not have any of the conditions listed under the contraindications
segment of this form and agree to receive Class 4 Laser treatment from Greenway Cotton Chiropractic. NO GUARANTEES – Because all
individuals are different it is not possible to completely predict the benefits from this treatment. By signing this form I acknowledge
that guarantees as to the final results of my treatment have not been made. Some individuals will have a very noticeable improvement
after their first treatment while others may have little or no improvement. I understand that additional treatments for additional fees
may be required to achieve my desired end result.

Release of Information
AUTHORIZATION FOR RELEASE OF RECORDS & PHYSICIAN’S LIEN

RELEASE OF RECORDS: I do hereby authorize the above doctor to furnish you, my attorney/insurance carrier, with a full
report of this case history, examination, diagnosis, treatment, and prognosis of myself in regard to my accident on record.
LIEN ON SETTLEMENT: I hereby give a Lien to the above doctor on any settlement, claim, judgment, or verdict as a result
of said accident. I authorize and direct you, my attorney/Insurance Carrier, to pay directly to said doctor all sums that are due
and owing, for services rendered me, by withholding such sums from any settlement, claim, judgment, or verdict as may be
necessary to protect said doctor adequately. Prior to dispersing any such fees, it is the responsibility of the payer to verify with
this office all outstanding balances.
ASSIGNMENT OF BENEFITS: I further assign my claim or right to compensation for treatment expenses incurred with the
doctor/clinic named above arising from a tort or liability claim in connection with this accident or injury.
IRREVOCABLE LIEN: I understand that this Lien shall be irrevocable either by myself or any other agent that represents
me; that in the event another attorney is substituted in this matter, the new attorney shall honor this lien as inherent to the
settlement and enforceable upon the case as if it was executed by him.
RESPONSIBILITY FOR PAYMENT: I understand that I am directly and fully responsible to said doctor/clinic for
chiropractic bills submitted for services rendered me, and that this agreement is made solely for said doctor’s additional
protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any
settlement, claim, judgment, or verdict by which I may eventually recover said fee. In the event that there is a deductible or copay to be satisfied, I understand and agree to pay any deductible or co-pay required by any insurance company that is billed for
me. I understand that if my insurance policy contains Med Pay, PIP, Underinsured/Uninsured Greenway Cotton Chiropractic
will bill my policy for reimbursement and provide proof of payment to my attorney/the at fault party. I also understand and
agree that I am responsible for any reasonable collection fees required to secure the doctor’s payment

NOTICE OF PRIVACY PRACTICES
Abridged Edition
Effective April 14, 2003, the Department of Health & Human Services has implemented protection for patient health care information. It outlines who we may
disclose information to without your authorization and how we can disclose your protected health information with your authorization as well as how you can
gain access to your personal health information or to make a complaint to the Department of Health & Human Services if you feel your protected health
information was used in an improper way. This notice will give you a brief description of our entire privacy practices.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
So that this office can treat you, receive payment for that treatment and run our health care operation, we may use your protected health information without
your authorization to send to third party payers, administrators, etc.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION THAT MAY BE MADE WITH YOUR WRITTEN AUTHORIZATION
With your signed authorization we may make communications with you to promote products and services that may not be for a specific purpose of providing
treatment advice. You have the right to revoke this authorization. Other permitted and required uses and disclosures that may be made without your
authorization or opportunity to object – we may disclose to a member of your family, a relative, a close friend or other person you identify, your protected
health information that directly relates to that person’s involvement in your health care. We may also disclose your protected health information to an
authorized public or private entity as required by law.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT
We may use or disclose your protected health information in the following situations:
 Required by law
 Health Oversight
 Legal Proceedings
 Research
Your rights – You may inspect or obtain a copy of your protected health information for as long as we maintain that information unless protected by federal
law.
RIGHT TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION
You may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or health care operation. Also, you
may request that any part of your protected health information not be disclosed to your family members or friends who may be involved in your care. Your
request must be in writing and state specific restrictions requested and to whom it applies.
RIGHT TO REQUEST TO RECEIVE CONFIDENTIAL COMMUNICATION FROM US BY ALTERNATIVE MEANS OR AT AN ALTERNATIVE LOCATION
You may request that you receive these communications from us at an alternative location or by alternative means than is normally provided to other patients.
RIGHT TO AMEND YOUR PROTECTED HEALTH INFORMATION
You may request an amendment to your protected health information for as long as we maintain your protected health information. In certain cases we may
deny your request for an amendment.
RIGHT TO RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSRUES WE HAVE MADE
You have the right to receive an accounting if we receive a request for disclosure of information for purposes other than treatment, payment and health care
operations
RIGHT TO OBTAIN A PAPER COPY OF THIS NOTICE
You have the right to receive a complete copy of our privacy practices by paper or electronically.
COMPLAINTS
If you believe your privacy rights have been violated, you may complain to us or to the Secretary of Health & Human Services. This notice was published and
becomes effective (updated) January 1st, 2018.

HIPAA Privacy Rule: Consent for Purposes of Treatment, Payment and Healthcare Operations
I acknowledge that Greenway/Cotton Chiropractic “Notice of Privacy Practices Abridged Edition” has been provided to me.
I understand I have a right to review the entire Greenway/Cotton Chiropractic Notice of Privacy Practices prior to signing this document.
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 Greenway/Cotton Chiropractic. The Notice of Privacy
Practices for Greenway/Cotton Chiropractic also provided on request at the main administration desk of this practice. This Notice of
Privacy Practices also describes my rights and Greenway/Cotton Chiropractic duties with respect to my protected health information.
Greenway/Cotton 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 by calling the office and requesting a revised copy be sent in the mail or asking for one
at the time of my next appointment.