BB Chiropractic- New Patient Packet

HIPAA Notice & Acknowledgment
Yor Privacy Rights
We are committed to protecting your health information. Your information may be used for treatment, payment, and healthcare operations as required by law. A copy of our Notice of Privacy Practices is available at the front desk and upon request.
I acknowledge that I have been offered and have had the opportunity to review the Notice of Privacy Practices.
Signature*
Type your full name as your signature
Date*

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Informed Consent to Chiropractic Care
Chiropractic care focuses on supporting the nervous system and musculoskeletal system so the body can function, adapt, and heal as efficiently as possible. Care is gentle, individualized, and appropriate for each person's age, size, and health history. I understand that chiropractic care does not diagnose or treat disease, that results may vary, and that no guarantees have been made regarding outcomes
I consent to chiropractic evaluation and care for myself / my child
Signature*
Type your full name as your signature
Pediatric Consent

(Minors Only)
Parent/Guardian Signature*
I am the legal parent or guardian and consent to care
Date

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Financial Policy & Insurance
Payment is due at the time of service unless prior arrangements are made. Belleair Bluffs Chiropractic accepts some insurance plans. Insurance benefits are verified as a courtesy and are not a guarantee of payment. Patients are responsible for any balance not covered by insurance
I understand and agree to the financial policy
Insurance Plan
Leave blank if uninsured
Method of Payment for First Visit
Signature*
Type your full name as your signature
Date*

MonthDayYear
Date

Communication & Media Consent
I consent to reminders via text/emailI do not consent
Photo / Video Consent
From time to time, photos or videos may be taken for clinical documentation, education, or marketing purposes. No identifying information will be shared without your explicit permission. Participation is completely voluntary and will not affect your care
Yes, I give permission for photos/videosNo, I do not give permission
Signature*
Type your full name as your signature
Date*

MonthDayYear
Date
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New Patient Information