R.E.N Chiropractic Treatment Intake Form

R.E.N Chiropractic Privacy Policy

R.E.N Chiropractic's Privacy Policy governs the collection, use, and disclosure of personal information obtained from patients and visitors to their clinic. Key points include:

1. Information Collection: Various personal details are collected for patient care and administrative purposes.

2. Use of Information: Information is utilized for chiropractic care, appointment management, billing, communication, and legal compliance.

3. Information Security: Measures are implemented to safeguard the confidentiality and integrity of personal information.

4. Third-Party Disclosure: Personal information is not sold but may be shared with trusted third parties for care, billing, or legal compliance purposes.

5. Consent: Patients provide consent for the collection, use, and disclosure of their personal information as outlined in the policy.

6. Retention of Information: Patient records are retained for the required legal period and securely disposed of afterward.

7. Access and Correction: Patients have the right to access and request corrections to their personal information.

8. Cancellation Fees Charges: Information regarding cancellation fees charges is included in the Privacy Policy, outlining any applicable fees and the circumstances under which they may be incurred.

9. Changes to Privacy Policy: The policy may be modified, with changes taking effect immediately upon posting on the website or direct notification to patients.

10. Contact Information: Individuals can reach out to R.E.N Chiropractic for inquiries or concerns about the Privacy Policy via provided contact details.

Patients are encouraged to review the full policy, with any updates promptly communicated to them.
R.E.N Chiropractic Treatment Intake Form

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Date*

DayMonthYear
Date
Full Name*

First NameLast Name
Birth Date*

DayMonthYear
Contact Number*
Phone number
E-mail*
Address

Street Address

Suburb

CityState

Postal CodeCountry

Patient information are confidential and written authorization is required to release any information.

We do not double book appointments

Please reschedule session if more than 15 minutes late

24 hour cancellation notice is required

You will be draped and at no time be exposed

You will have a consultation with your therapist to discuss the session

You my end the session at any time for any reason

Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Patient Agreement:

I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder.

I acknowledge that chiropractic treatment is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.

I understand that at any time I feel pain or discomfort during the session, I will immediately inform my chiropractor.

I have stated my pertinent medical conditions, and will update the chiropractor of any changes in my health status.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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R.E.N Chiropractic Treatment Intake Form

Health Information