CONSENT TO TREATMENT / FINANCIAL AGREEMENT

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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 treatments, non-surgical bunion therapy, 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 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 reposition the misaligned big toe where the bunions is 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 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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