Intake Form (Part 2 of 2)

This is the online version of the Informed Consent form.  Please be aware that though this page is encrypted the form data will be sent via email and could, theoretically, be intercepted and/or read by third parties after it has left this site.  If you are not comfortable providing information with this form due to privacy concerns please download, print, and fill out the PDF VERSION OF THIS FORM and bring it with you on your first office visit.

Please make sure you also fill out Part 1 of the Intake Form regarding your current health issues.

General Information

 

Birth History

 

Personal History

  • Chiropractic care is based on the location and adjustment of vertebral subluxations and extremity subluxations. These are caused by any stress on your body which your body cannot properly perceive, adapt to, or recover from. These stresses can be PHYSICAL, CHEMICAL, or EMOTIONAL in nature. To help you better in any of these areas, please answer the following questions:
  • If you have ever suffered from, or are undergoing, any form of abuse, please answer the following questions:
 

Informed Consent for Chiropractic Care

  • You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment that will be provided at this clinic. You may make the decision whether or not to use chiropractic care after being advised of the known risks, benefits, and alternative.

    Chiropractic is a science and an art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect both the restoration and the preservation of health.

    Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity

    One disturbance to the nervous system is called vertebral subluxation. This occurs when one or more of the twenty-four vertebrae in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.

    Subluxations are corrected and/or reduced by an adjustment (a specific application of forces to correct and/or reduce the vertebral subluxations). our chiropractic method of correction is by specific adjustment of the spine. In this clinic this is usually done by hand, but may be performed by handheld instruments. In addition, ancillary procedures such a physiotherapy and/or rehabilitative procedures may be included.

    If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider.

    All questions regarding Dr. Clarke's objective pertaining to the care in this clinic has been answered to my complete satisfaction. The benefits, risks, and alternatives of chiropractic care have been explained to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis

  • Note: Upon you first office visit you will be asked to formally sign a consent form stating the same terms as above. If you are seeking services for a child or minor you will also have to consent to that evaluation or adjustment separately.

  • This is to let you know how your Patient Health Information (PHI) is going to be used in this office, plus let you know your rights concerning our record (HIPAA).

    Before I begin any health care procedure, I request that you read and sign this consent form stating that you understand and agree with how your records will be used:

    1. You understand and agree to allow The Healing Circle (THC) (Dr. Susan Clarke and her staff) to use your PHI for the purpose of treatment, payment, healthcare, operations, and coordination. You agree to allow Dr. Clarke to submit requested PHI to the Health Insurance Company (or companies) for payment.
    2. You have the right to examine and obtain a copy of your records at any time. You may request corrections. you may ask to know what disclosures have been made and submit, in writing any further restrictions on the use of your PHI. Dr. Clarke is not obligated to agree to those restrictions
    3. Your written consent need only be obtained one time for all subsequent care given to you at this office.
    4. You may provide a written request to revoke consent at any time during care. This would not affect the use of those records covering the care given prior to the written request, but would apply to any care given after the request is presented.
    5. For your security and right to privacy, all staff at Dr. Clarke's clinic have been trained in the area of patient record privacy and Dr. Susan Clarke has been designated to enforce those procedures. Dr. Clarke has taken all precautions known by this office to assure your records are not readily available to others.
    6. You have a right to file a formal complaint with Dr. Susan Clarke about any possible violation of these policies and procedures
    7. If you refuse to sign the consent for the purpose of treatment, payment and health care operations Dr. Susan Clarke has a right to refuse to give care.
    9. You understand that this online form is not HIPAA-compliant nor secure and you submit it over the Internet at your own risk, fully aware there is no guarantee of privacy for the information you provided voluntarily during transmission or storage

    I have read and understand the policies and procedures regarding usage of my Patient Health Information, and I agree to these policies and procedures.

 

Verification