New Practice Member Questionnaire Child (12 or younger)

I acknowledge that I have had the opportunity to review Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC’s "Notice of Privacy Practices" on the practice’s website. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC’s duties with respect to my protected health information. Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment.

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 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, stroke, dislocations, strains, and sprains. With respect to stroke, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Stroke caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur 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. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and risk of death has been estimated as 104 per one million users. 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. I authorize Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC to electronically send me announcements, notices, updates, patient education and office related correspondence and other information related to our practice and services using electronic communications mediums including, but not limited to, the internet, email, phone, text messaging, video and voicemail.

I hereby consent to examination and all treatments of myself or my minor dependent(s) for whom I am responsible. I guarantee payment for all services rendered regardless of my results or whether my insurance company(s) contributes or does not contribute toward payment for my care or care of minor dependent(s). I authorize Madeira Chiropractic Wellness Center, Inc. & Madeira Total Health LLC to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, test results, governmental agencies, etc. as required by law and allowed by law. Patient agrees to pay all fees if it becomes necessary to enlist a collection agency or law firm to collect a past due balance. Patient agrees to be responsible for all costs of collection on unpaid balances including, but not limited to, 1.5% interest (18% annually), collection fees (up to 50%), court costs and reasonable attorney fees.

I, the undersigned, being the parent and/or legal guardian of the above-referenced minor(s) consent to and request that he/she be examined, evaluated and treated at this office within the scope of Doctor of Chiropractic (D.C.) services rendered which may include but are not limited to x-rays, examinations, evaluations, diagnoses, and treatment as chiropractically indicated and/or are recommended or directed by our Doctor(s) of Chiropractic or other qualified staff of Madeira Chiropractic Wellness Center, Inc. or Madeira Total Health LLC This consent shall be valid from this date forward until this applicable case is resolved or withdrawn by the undersigned. I, the undersigned, understand that I am responsible for, and agree to pay for any and all outstanding monies due for services rendered hereunder and understand that I must notify Madeira Chiropractic Wellness Center, Inc. or Madeira Total Health LLC IN WRITING of my intent to withdraw my consent.