Patient Registration and Informed Consent

Authorization To Release Information/Financial Agreement

I authorize the release of any medical information necessary to process my claims. I hereby authorize Integrated Health Solutions Inc. and all IHS Chiropractic Physicians, hereinafter referred to as IHS/ all IHS Chiropractic Physicians/CTI, to apply for benefits on my behalf for services rendered by them. I request that payment from my insurance company be made directly to IHS/ all IHS Chiropractic Physicians/CTI. I permit a copy of the authorization to be used in place of the original. My insurance company or I may revoke this authorization at any time. This revocation must be submitted to IHS/ all IHS Chiropractic Physicians/CTI in writing. I am responsible for all copays/coinsurances, which are due and payable at the time services are rendered, as well as deductible amounts. If my insurance carrier and policy determines that certain services are not medically necessary, investigational or experimental or denies the claim for any reason please be advised that I am responsible for payment of these services provided as a part of my agreed upon treatment plan. If further action ever becomes necessary and is taken in order to collect any delinquent balance due on my account, I agree to pay for all collection, attorney, and court fees incurred by IHS/ all IHS Chiropractic Physicians/CTI for the collection of any and all balances due on my account. I am aware that 1.5% interest is added on all account balances each month.

By providing the email address listed above, I understand that I will be added to the IHS/ all IHS Chiropractic Physicians/CTI monthly newsletter. I understand that I have the option to unsubscribe at any time. I also understand that my phone number will be added to the IHS/ all IHS Chiropractic Physicians/CTI healthy tip text club and that I have the option to opt out at any time. By my signature below, I acknowledge: I have read and understand the preceding statements regarding my
insurance, as well as my financial responsibilities, including if insurance does not pay. I am responsible for any outstanding balance on my account.

In the event of any litigation arising out of the terms of this agreement, IHS/ all IHS Chiropractic Physicians/CTI shall be entitled to recover all reasonable attorney’s fees and costs incurred during the prosecution of said litigation, including fees and costs incurred on appeal, as well as costs associated in the collection of any judgment, should IHS/ all IHS Chiropractic Physicians/CTI be the prevailing party on any issue. I agree that my financial responsibility for payment of services as mentioned above can be adjudicated in a court of law including Small Claims Court, as opposed to mediation/arbitration. All other claims (personal injury, medical negligence, premises liability, etc.) must be adjudicated through mediation/arbitration.

I also understand that my sole remedy and IHS/ all IHS Chiropractic Physicians/CTI’s sole liability for claims of any kind or nature as to services provided shall be limited only to the amount of compensation of services paid to IHS/all IHS Chiropractic Physicians/CTI. The parties agree that a mutually selected third party mediator will mediate all such disputes. If the mediation is deemed unsuccessful, the parties agree that the dispute will be directly submitted to binding arbitration under rules issued by the American Arbitration Association. The decision of the arbitration shall be final. IHS/ all IHS Chiropractic Physicians/CTI shall be entitled to recover all reasonable attorney’s fees and costs incurred during this mediation or arbitration.

Authorization for Medical Treatment and Informed Consent

I authorize IHS/ all IHS Chiropractic Physicians/CTI to provide an evaluation and medical treatment. At IHS/ all IHS Chiropractic Physicians/CTI the treatment is integrative, and the doctors use a variety of therapies and procedure to treat you. As a part of the analysis, examination, and treatment, you are consenting to the following procedures: spinal manipulative therapy, range of motion and muscle strength testing, palpation, orthopedic testing, postural analysis, hot/cold therapy, traction, normatec, vital signs, basic neurological testing, acupuncture, dry needling, whole body cryotherapy, floatation therapy, infrared sauna, taping, nutritional supplements/ dietary recommendations, cryotherapy, IV nutrition among other treatments or procedures that the doctor may deem necessary. As with any healthcare procedure, there are certain complications, which may arise during treatments and therapy. At IHS/ all IHS Chiropractic Physicians/CTI, the doctor will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to the doctor’s attention, it is your responsibility to inform the doctor.

I have voluntarily requested that the doctors of chiropractic at IHS/ all IHS Chiropractic Physicians/CTI (herein ‘the doctor(s)’ to assist me in the management of my health concerns. I understand that the doctors are chiropractors and that their services are not to be construed or serve as a substitute for standard medical care.

Chiropractic Manipulation

Joint fixations, dysfunctions or restrictions create interference with the transmission of proper neuro-electrical communication through the spine and extremities. This can cause decreased joint motion, pain, discomfort and/or a lessening of the body’s ability to function properly. Chiropractic focuses on conditions stemming from restricted joint motion, mainly of the spine and related nervous system, and the effects of these disorders on general health. Chiropractic Manipulation Therapy (CMT) is designed to centrate the joint and thereby returning the complex into balance. This treatment may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Risks:
Soreness: Some patients will feel some stiffness and soreness following the first few treatments.
Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Please inform the doctor if you experience these symptoms.
Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities, or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disk, or other abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency cerebrovascular accidents following chiropractic adjustments are extremely rare and are typically associated with underlying cardiovascular disorder. I am aware that the incidence of nerve or brain damage including stroke is reported to occur between 1-10 per 10 million incidences. I freely assume these risks.
Other: other complications include but are not limited to, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, arterial dissection, nerve injuries or nerve compression.

Acupuncture / Dry Needling
Acupuncture / Dry needling involves inserting a tiny monofilament needle in a muscle(s) in order to release shortened bands of muscles and decrease trigger point activity. This can help resolve pain and muscle tension, and will promote healing. Dry needling is not traditional Chinese acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Dry needling is a valuable and effective treatment for musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare in occurrence, they are real and must be considered prior to giving consent for treatment.

Risks in Acupuncture / Dry needling: The most serious risk with dry needling is accidental puncture of a lung (pneumothorax). If this were to occur, it may likely require a chest xray and no further treatment. The symptoms are shortness of breath may last for several days to weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include, soreness, bruising, infection, bleeding, damage to internal organs, puffy vein, and/or nerve injury.

Have a bleeding disorder. Your chances of bleeding or bruising from the needles increase if you have a bleeding disorder or if you're taking blood thinners, have a pacemaker. Acupuncture that involves applying mild electrical pulses to the needles can interfere with a pacemaker's operation Are pregnant. Some types of acupuncture are thought to stimulate labor, which could result in a premature delivery.

Soft Tissue Mobilization

I understand that the soft tissue techniques that I receive are provided for the purpose of relaxation and relief of muscular tension. The doctor will use his/ her hands, an instrument, or both with the use of Biofreeze or massage cream. If I experience any pain or discomfort during the treatment, It is my responsibility to immediately inform the doctor so that the pressure and/or strokes may be adjusted to my level of comfort, or discontinued all together. Common risks include, soreness and bruising.

Treatment Results

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits.
I realize that the practice of medicine as well as chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures.
I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.

Alternative Treatment Options
Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest, medical care and prescription drugs such as antiinflammatory, muscle relaxants and pain-killers, hospitalization, surgery. If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. Remaining untreated may allow the formation of adhesions and reduce mobility, which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
• Reasonable alternatives to these procedures include rest, home applications of therapy, prescription or over- the-counter medications, exercises and possible injections and/or surgery.
• Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks. We cannot advise you regarding any medication/s. Please consult your M.D.
• Rest/Exercise: Simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues if not done properly.
• Surgery: Surgery may be necessary for conditions such as joint instability or serious disk rupture, among others. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.
• Non-treatment: I understand the potential risks of refusing/neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthier.

I have read or have had read to me the above explanation of IHS/ all IHS Chiropractic Physicians/CTI treatments including dry needling. I have the choice to ask for more detailed explanation; but I am satisfied with the explanation and do not want any further information. I have made my decision voluntarily and freely. I am aware that multiple treatment sessions may be required and are not intended to replace other components of my care plan. I am aware that after signing this document, if I experience any change in my health status, especially any type of infection or condition noted, I am to notify my provider immediately to determine if dry needling is still an appropriate intervention. To attest to my consent to these examination and current and/or future treatment procedures despite potential risk, I hereby affix my signature to this Informed Consent document.

Notice of Privacy Practices
A copy of the Privacy Practices Declaration is present upon request.

Duration of Consent

This consent remains in effect for as long as you continue to receive services from our practice. You may revoke this consent at any time by providing written notice.