Hendersonville - New Patient Paperwork

Authorization to treat

I understand that no guarantees have been made concerning my recovery as every individual responds to Chiropractic differently. I hereby authorize Abrahamson Chiropractic & Wellness and whomever they may designate as an assistant to administer therapies and take x-rays if needed. I have read and understand the office policy stated above and agree to accept responsibility as described.

Abrahamson Chiropractic & Wellness Informed Consent to Care

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures, if indicated. Any examinations or tests conducted will be carefully performed, but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including, but not limited to, hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people, whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

Both parties agree that this agreement may be electronically signed, and that the electronic signatures appearing on this agreement are the ame as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Authorization to release insurance and treatment information

I hereby instruct and authorize my insurance company to release information concerning my coverage and benefits for both health/auto insurance and pay by check made out and mailed directly to: Abrahamson Chiropractic & Wellness, 165 Indian Lake Blvd., Suite 102 Hendersonville, TN 37075.

I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this Chiropractic Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

I authorize Abrahamson Chiropractic & Wellness to release and gather any or all my medical records as deemed necessary to/from other health care providers. I also authorize release of records to my insurance company as requested to facilitate payment to Abrahamson Chiropractic & Wellness. I understand this office will take all necessary precautions to insure my privacy. I have been given a copy of the HIPAA regulations for my review.

I understand that my account is considered delinquent if over 90 days old and may be sent to an outside source for collection. I agree that if Abrahamson Chiropractic & Wellness initiates collection efforts to recover amounts owed on my account, then, in addition to amounts owed for services rendered, I will pay any and all costs incurred by Abrahamson Chiropractic & Wellness in pursuing collection, including, but not limited to, reasonable attorney fees, and any court costs or other costs of litigation incurred in collecting my delinquent account.

I have read and understand the office policy stated above and agree to accept responsibility as described.

This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. By signing below, I acknowledge that I have been made aware of its availability.

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.