Bunion Treatment New Client Intake Forms

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CONSENT TO TREATMENT / FINANCIAL AGREEMENT

Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and benefits of the treatment, and any alternatives to the treatment provided. There are some inherent risks that may be associated with chiropractic treatments, acupuncture therapy, non-surgical bunion treatments, and non-surgical face-lifts, including, but not limited to:

• Aggravation of pre-existing symptoms

• Allergic reactions to supplements or herbs

• Rib fractures or muscle and ligament sprains or strains following treatment.

• Disc injuries following cervical and lumbar spinal adjustment (although no scientific study demonstrates such injuries are caused, or may be caused, by spinal or soft tissue manipulation or treatment).

• Vertebral artery injury following osseous spinal manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with serious neurological impairment, and may, on rare occasion, result in paralysis or death. The possibility of such injuries resulting from cervical spine manipulation is extremely remote.

• Pain, Bruising, or swelling associated with bunion therapy especially at the calf, ankle, and foot.

• Some skin reaction to topical analgesic solution used in the bunion procedure therapy to help relieve joint pain.

Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions including general pain and loss of mobility, headaches and other related symptoms. Musculoskeletal care contributes to your overall well-being. The risk of injuries or complications from treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

________ I acknowledge I will have the opportunity to discuss the following with my healthcare provider:

a. The condition that the treatment is to address;
b. The nature of the treatment;
c. The risks and benefits of that treatment; and
d. Any alternatives to that treatment

I voluntarily consent to outpatient care at Surgical Alternatives, encompassing routine diagnostic procedures, examination and treatment including, but not limited to, chiropractic adjustments, acupuncture therapy, non-surgical bunion therapy, non-surgical face-lifts, and chronic pain relief treatments.

I further consent to the performance of these diagnostic procedures, examinations and rendering of treatment by the staff. I understand that some treatments are considered experimental and that some treatment or suggestions provided are NOT accepted by the United States FDA. I therefore, hereby release Dr. Robert Levingston, D.C., FIAMA from any liability arriving out of the status of the approval or lack of approval of these therapeutic procedures.

I agree to inform Dr. Levingston immediately of any disease process that I am suffering from, or if I am on any medication or over the counter drugs; (If you are pregnant or you are breast-feeding please advise Dr. Levingston immediately).

________ I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent, unless required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee.

________ I understand that Dr. Levingston will answer my questions that I have to the best of his ability. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.

I understand that bunion treatment therapy is not a substitute for surgery but merely a treatment involving strengthening the muscles of the foot (particularly the abductor hallicus) as an attempt to help correct the hallux valgus deformity and re-position the misaligned big toe where the bunions are located. As in all healthcare cases, in regards to bunion therapy, results may vary and there is no guarantee that one patient will have the same result as another.

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, including chiropractic and bunion therapy, is not an exact science and I acknowledge that no guarantee has been made to me regarding that outcome of these procedures.

I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and soft tissue manipulation and bunion treatment therapy. I intend this consent to apply to all my present and future care with Dr. Levingston or other licensed doctors of chiropractic who now, or in the future, treat me while employed by, working for or serving as back-up for Dr. Levingston, D.C., FIAMA.

_________ I understand that all charges are to be paid at the time of the visit. Payments for all dispensary items such as supplements, serums, or solutions are due at the time of the visit.

I understand and agree that as the patient, I am responsible for the total charges incurred for each visit including costs of supplements. I understand that most insurance companies do not cover the cost of alternative therapies or supplements. I have read and understood the above stated policies and information. I intend this consent form to cover the entire course of treatment(s) for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
______________________________ ______________________________ _________________
Signature of Patient Name of Patient (Printed) Date Signed

______________________________ ______________________________ _________________
Signature of Legal Representative Relationship Date Signed
(e.g. attorney-in-fact, guardian, parent if minor)

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PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

I, ______________________________________ hereby state that by signing this Consent, I acknowledge and agree as follows:
(Printed Name)

1. The Practice’s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.

2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.

3. I understand that, and consent to, the following appointment reminders that may be used by the Practice: a) a postcard mailed to me at the address provided by me; b) telephoning my phone and leaving a message on my answering machine or with the individual answering the phone; c) e-mail sent to the e-mail address provided by me; and d) text message sent to my mobile device capable of receiving text messages after receiving notice that I prefer this type of notification. I understand that standard text rates may apply from my mobile service provider.

4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.

5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.

6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.

7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.

8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.
______________________________ ______________________________ __________________
Signature of Individual Name of Individual (Printed) Date Signed

______________________________ ______________________________ _________________
Signature of Legal Representative Relationship Date signed
(e.g. attorney-in-fact, guardian, parent if minor)

 

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Non-Surgical Bunion Treatment Guidelines

Patient Name: _________________________________

Date: __________________
(Please Print)
Please read and initial next to each line. By initialing next to each line, you are indicating that you understand and agree to adhere to the following Bunion Treatment guidelines:

______ I agree to perform my exercises and/or walking re-education, as instructed by Dr. Levingston, for a minimum of 20-minutes per day (10 solid minutes each set) for the duration of my 10-session bunion treatment.
______ I agree to limit and/or abstain from drinking alcohol or coffee during duration of the treatment period.
______ I will continue to perform my instructed exercises at home as a form of maintenance post bunion treatment to continue to strengthen and maintain my Hallux Valgus correction attained from the treatment with Dr. Levingston.
______ I agree not to wear tight fitting shoes, high heels, or sandals for the duration of my 10-session bunion treatment. I understand that not following this guideline could prevent me from receiving the full benefit of my bunion therapy and prevent me from meeting my intended goals.
______ I agree to limit tight fitting shoes, high heels, or sandals post bunion treatment. I understand that not following this guideline could potentially reverse any Hallux Valgus correction attained during my bunion treatment.
______ I agree to stay hydrated by drinking the recommended amount of water:
Recommended Daily Water Intake: ______ Ounces / ______ glasses of water

Patient Signature: ________________________________

 

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New Patient Intake Form

Today’s Date: ____/____/______

Patient Name: __________________________¬¬¬________________ Date of Birth: ______/______/_______ Age: __________
Address __________________________________________ City _________________ State ______ Zip Code ____________
Home Phone: ____________________ Work Phone: _____________________ Cell Phone: _____________________
Email: _____________________________________ Sex: 0 Male 0 Female Marital Status: 0 Single 0 Married
Employment Status: 0 Employed 0 Unemployed 0 FT Student 0 PT Student 0 Other____________________
Employer Name: ____________________________________ Occupation: _________________________________________
Employer Address ____________________________________ City ____________________ State_____ Zip Code _________
Primary Care Physician ___________________________________ Phone #: _________________ Last Visit _____________
Emergency Contact Name: _________________________________ Relationship to Patient: __________________________
Emergency Contact Phone #: ____________________________ Alternative phone: ______________________________
Reason for Visit: 0 Non-Surgical Bunion Repair 0 Hair Renewal 0 Non-Surgical Facelift 0 Acupuncture
0Chiropractic 0 Other: ___________________________ How did you hear about us? __________________________
I will be paying by: 0 Cash 0 Credit / Debit card
I have completed and reviewed the above information and to the best of my knowledge it is accurate. I authorize the individual physicians to advise me of any necessary procedures, diagnostic studies and treatment. I will notify you of any changes in my status of the above information.
Patient Signature: Date:
(Patient or Parental Signature if Patient is a Minor)
Medical Conditions (Check all that apply):
0 Arthritis 0 Cancer 0 Diabetes 0 Heart Disease
0 Hypertension 0 Psychiatric Illness 0 Skin Disorder 0 Stroke
0 Headaches 0 Multiple Sclerosis 0 Epilepsy 0 GI
0 Urinary 0 Ears, Nose, Throat 0 Back 0 Neck
0 Other: _________________________________________________________________________
Past Medical History: ______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Surgeries (Please list ALL surgeries and hospitalizations): _________________________________________________________
________________________________________________________________________________________________________
Allergies: ________________________________________________________________________________________________
Social History (Check all that apply):
Caffeine use: 0 Occasional 0 Often 0 Never
Drink Alcohol: 0 Occasional 0 Often 0 Never
Exercise: 0 Occasional 0 Often 0 Never
Cigarettes: 0 <1 pack/day 0 >1 pack/day 0 Never
Family History (Check all that apply):
Arthritis: 0 Parent 0 Sibling
Cancer: 0 Parent 0 Sibling
Diabetes: 0 Parent 0 Sibling
Heart Disease: 0 Parent 0 Sibling
Hypertension: 0 Parent 0 Sibling
Stroke: 0 Parent 0 Sibling
Thyroid: 0 Parent 0 Sibling
Other: ___________________________________________________________________________
Current Medication/Vitamins: _______________________________________________________________________________
_______________________________________________________________________________________________________
Are you pregnant? Yes ______ NO _______ N/A ________
The statements on this form are correct to the best of my recollection. I understand that I am financially responsible for all charges. I understand that Dr. Levingston dos not bill insurance and payment is due at the time of service.

Patient Signature: ______________________________________ Date: ____________________________

 

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BUNION QUESTIONNAIRE

Patient Name: ______________________________ Date: __________________

Please answer the following questions with as much detail as possible:

How long have you been suffering from bunions?
Do your bunions make it difficult and/or painful to walk?
Do you believe your bunions are causing you to have foot and/or back pain?
Do your bunions prevent you from fun activities or exercising?
Do you feel that your bunions are causing your feet to look deformed or unattractive?
Are you self-conscious about showing your feet in public?
Is it hard to find shoes that fit?

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Learn more about our alternative bunion treatment. Start your consultation today. Call us at 303-532-4844, or use our consultation form shown below to send us information and pictures. You can also request a Free Report.