* This form is only to be filled out after you have paid a deposit to reserve a date for the Spero Clinic program.
Dr. Katinka van der Merwe and the team here at Neurologic Relief Center/Integrated Health & Wellness are dedicated to providing you with the best care possible, with the goal of you reaching your optimal health and function. For that reason, we will always recommend everything you need for the benefit of your condition and will not make recommendations based only on what your insurance will cover. The decision to proceed with care is always up to you, the patient, since your healthcare choices are a personal decision. With that in mind, this notice will help you understand that several of the services or procedures performed in this office are designated "unproven" by the Arkansas State Board of Chiropractic Examiners and their effectiveness has not been demonstrated. "Unproven" means that the service or procedure is one that is not generally recognized or does not have scientific validity whose research was not sponsored, and investigative findings have not been printed in scientific journals."Unproven" procedures may also be identified by state guidelines and/or 3rd party payors as "investigational procedures" or "experimental procedures". This status does not indicate that the procedures are not allowed or are not effective. However, this status does indidcate that the services with this status have not been through the approval process as required by FDA and/or other governing entities.
This includes those items listed below:-Manual Vagus Nerve Stimulation
-Piezo Scar Tissue Treatment
-Electric Stimulation-Low Level Laser Therapy
-EWOT Oxygen Therapy
-Magnetic Resonance Therapy
-Frequency Specific Microcurrent
By signing this form, the patient understands that the services listed above are designated as "unproved" by the State Board of Chiropractic Examiners and therefore, will not be billed to a 3rd party payor.
Please read and sign the information below to complete your medical history profile. Thank you for helping us understand you, and what your needs will be moving forward. All of our sincere thanks.
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of Chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. Terms of Acceptance:When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both parties to be working towards the same objective.Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to obtain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of force to facilitated the body's correction of the vertebral subluxation. Our chiropractic methods of correction is by specific adjustment of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae of the in the spinal column which causes alteration of the nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express is maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if, during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider that specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.I have read and understand the above statement. I accept chiropractic care on this basis.