Robert Curtis D.C. P.S.dba Advanced Sports Chiropractic
Confidential Patient Information

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Cash Financial Policy

Many insurance companies do not cover ancillary procedures such as:

  • 97110 – Therapeutic Exercises (stretching, core strengthening, tubing, etc.)
  • 97140 - Manual Therapies (Graston Technique, etc.)
  • 97124 - Massage Therapies (effleurage, compression, tapotement)

By signing below, you agree to pay Robert E. Curtis, D.C., P.S. for one or more of these services that are outside of your insurance plan, if your plan allows. A time of service discount will be applied to the charges incurred, and shall be paid for at the time of service. Special considerations for payment plans are on a case by case basis.

Signature ______Date______

Insurance Financial Policy

  • I understand insurance policy arrangements are between an insurance carrier and myself.
  • I understand my insurance payments must be paid and current. If insurance is not valid at time of visit, payment is my responsibility.
  • Payment is expected at the time services are rendered unless arrangements are made in advance. My signature will act as authorized payment of medical benefits to Robert E. Curtis D.C., P.S.
  • I understand this office will prepare the necessary insurance reports and forms on my behalf, but will not be held responsible for lack of payment by my insurance company.
  • I am ultimately responsible for any amount not paid by my insurance company. If I suspend or terminate care, any fees for services rendered will beimmediately due.
  • This office has a 24-hour cancellation policy. I understand no-show appointments amount to a $30 fee.

Signature ______Date______

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures by Dr. Robert E. Curtis and/or other licensed doctors of chiropractic who now or in the future may practice in, work or be associated with, or be employed by Robert E. Curtis, D.C., P.S., currently located at Advanced Sports Chiropractic, 2101 Cornwall Ave #102, Bellingham, WA 98225.

I have had an opportunity to discuss with Dr. Curtis the nature and purpose of chiropractic adjustments and other procedures.

The following points have been explained to me, to my satisfaction, and I have had opportunity to discuss them with Dr. Curtis and/or clinic personnel:

1.Chiropractic care is the science, philosophy and art of locating and correcting spinal and extremity joint dysfunction (subluxation), and as such, is oriented toward improvement of spinal function relative to range-of-motion, muscular, and neurological aspects. There has been no promise, implied or otherwise, of a cure for any symptom, disease, or condition as a result of treatment in this clinic. If during the course of a chiropractic examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, a diagnosis or treatment for these findings, we will recommend that you seek the services of a health care provider who specializes in that area.

2.I understand that the chiropractor will use his/her hands or a mechanical device upon my body to adjust a joint which may cause an audible “pop” or “click”

3.As with the practice of medicine, the practice of chiropractic is not an exact science, but relies upon information related by the patient, information gathered during examination, and the doctor’s interpretation thereof, as well as the doctor’s judgment and expertise in working with like cases.

4.It is not reasonable to expect my chiropractor to be able to anticipate, or explain all possible risks and complications of a given procedure on any particular visit and I wish to rely on the doctor to exercise professional judgment during the course of any procedures, which he/she feels at the time to be in my best interest.

5.An undesirable result, or side effect, does not necessarily indicate error in judgement or an improper treatment.

6. As with any health care procedure there are certain complications which may arise during a chiropractic adjustment, traction, manual therapy, massage therapy, ice or heat. Those complications include, but are not limited to, sprain/strain, dislocation, fractures, disc injuries, or cerebral-vascular accidents (stroke). The most recent studies (Journal of CCA, Vol 37, No. 2, June 1993) estimate that the incident of this type of stroke is 1 per every 3,000,000 upper neck adjustments. These complications are extremely rare occurrences.

I have read the above consent, or had it read to me, have had the opportunity to ask questions and receive answers, am comfortable with the information provided and consent to chiropractic treatment and management on that basis.

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Patient’s Printed Name Date

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Patient’s Signature Parent/Guardian