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, is 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.

Any payment 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.

Cards that have been used previously on file will be processed if primary card declines.

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

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. Authorization is valid until revoked by signer.

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.

By signing my name below, I acknowledge receipt of the above stated notice and my understanding and agreement to its terms.

I ____________________________________, give authorization to the following individuals listed below to:

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 can end it at any point.

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.

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.

Consent to Treatment of a Minor: By my signature below, I hereby authorize the spa and its therapists to provide massage and related services to my minor child or dependent as we deem necessary. Additionally, I have read, verified, and agree with all information on this form. I understand that I may be present during any massage received by child. This authorization is valid until and unless it is revoked by me in writing. Name of Parent or Guardian (please print):