HIPPA Form - Chiropractic Wellness Center of Hudson

Patient Name*

First Last

Date*

Email*

Phone*

Terms of Acceptance

The goal of our office is to enable patients to gain control of their health. To attain this, we believe communication is key. There are often topics that are hard to understand and we hope this document will clarify those issues for you. Please read the below and if you have any questions, please feel free to ask one of our staff members.

Informed Consent:

A patient, in coming to the chiropractic doctor, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities, or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he/she is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures what he/she is suffering from: latent pathological defects, illnesses, or deformities which would otherwise not come to the attention of the chiropractic physician. The chiropractic doctor provides a specialized, non-duplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at The Chiropractic Wellness Center of Hudson, Inc., I am authorizing them to proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.

Women only:

To the best of my knowledge:*

I AM pregnant
I am NOT pregnant

X-Ray Permission for diagnostic interpretation*

Give my permission
Do NOT give my permission

Cancellation Policy:

Appointments are in high demand and your advanced notice of the need to cancel or reschedule your appointment is greatly appreciated as it will allow another patient access to that appointment time.
ALL SAME-DAY CANCELLATIONS / RESCHEDULES / NO-SHOWS WILL BE SUBJECT TO A $50 FEE.

Cancellation Policy*

I acknowledge & understand Cancellation Policy above.

Consent to Evaluate and Treat a Minor:

Being the parent or legal guardian, I have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.*

Yes
Not Applicable

Communication:

In the event that we would need to communicate your healthcare information, to whom may we do so?

Communication*

Spouse
Children
Others
No One

Spouse's Name*

First Last

Children*

Others*

*May we leave messages regarding your personal healthcare information on any answering device? i.e. home answering machines or voicemails?*

Yes
No

Acknowledgement:

I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy.*