Acknowledgement Form

Name *

First Name

Last Name

Today's Date: *

MM

DD

YYYY

I understand that my appointment includes a chiropractic consultation and examination. If I qualify for care, I authorize the chiropractor to provide the adjustments and care he believes will best support my health recovery. I understand the care here is evidence-based and focused on addressing the underlying chiropractic condition. I also acknowledge that chiropractic is a distinct practice and does not claim to cure specific diseases or conditions. *

Yes

I acknowledge the use of video monitoring throughout the office, operated by the virtual receptionist, so she can effectively manage office operations. This includes assisting with my chiropractic adjustments by directing me to exam rooms and setting me up on tables, enabling accurate scribing during visits, and scheduling follow-up appointments. I understand this system enhances my care and office efficiency while ensuring my privacy in accordance with privacy laws. This requires me to check in and check out with her upon my arrival and departure from the office, unless otherwise directed. *

I understand

Due to a high demand for appointments, I understand missed appointments prevent the front desk from scheduling appropriately and keep others in need of care from being seen. I understand that if I can’t make a scheduled appointment, I need to contact the Chiropractic Health Institute at least three hours before my appointment time. *

Yes

I acknowledge that any insurance I may have is an agreement between the insurance carrier and me and that I am responsible for the payment of any covered or non-covered services I receive. *

Yes

I authorize the Chiropractic Health Institute to charge my credit/debit card for services received and/or missed appointment fees. I understand that my credit card details will be saved to a secure and encrypted electronic file for future transactions on my account, and the Chiropractic Health Institute will not have access to these credit card details. *

Yes

I give permission to receive text messages, calls, occasional cards, letters, emails, or health information from this office as part of my care. I understand that message and data rates may apply, and message frequency may vary. I can reply STOP to opt out of texts or HELP for assistance at any time. *

Yes

I may request a copy of the Privacy Policy, which explains how my personal health information is protected and shared only as needed for reimbursement from involved third parties. I understand my data will not be sold or distributed to any third parties for other purposes. *

Yes

I consent to sharing my health records with my healthcare team, including my primary care physician and other health specialists, for coordinated care. This may encompass reports, notes, and test results, handled in accordance with privacy laws. *

Yes

I have a primary care physician: *

Yes

No

To the best of my ability, the information I supply is complete and truthful. I will not misrepresent the presence, severity, or cause of my health concern. *

Yes