When a patient seeks chiropractic care and our office accepts the patient for treatment, it is essential that both the patient and the chiropractor share a common understanding of the goals and methods of care. Chiropractic care has a specific objective, and it is important that each patient understands both the objective and the procedures used to achieve it. This understanding helps prevent confusion or misunderstanding during the course of care.

Adjustment: A chiropractic adjustment is the application of controlled force to specific joints of the spine or other areas of the body to facilitate the correction of vertebral subluxations. Our chiropractic method of correction is performed through specific adjustments of the spine.

Health: Health is defined as a state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A vertebral subluxation is a misalignment or dysfunction of one or more of the 24 vertebrae in the spinal column. This condition may alter nerve function and interfere with the transmission of nerve impulses, potentially reducing the body’s natural ability to maintain optimal health. I hereby request and consent to the performance of chiropractic adjustments and neuro-spinal assessments. I understand that each individual has a different potential for healing and wellness; therefore, the results of chiropractic care cannot be predicted or guaranteed. Chiropractic care is widely recognized as one of the safest and most effective forms of conservative health care. I understand that, as with any health care procedure, there are some risks associated with treatment. However, these risks are considered extremely minimal. In rare instances, injury to the vertebral artery has been reported in association with treatment provided by medical doctors, physiotherapists, and chiropractors. For perspective: The estimated risk of stroke in the general population is 0.00057%. The estimated risk of death from taking aspirin or other anti-inflammatory medications is 0.04%. The estimated risk of stroke following a chiropractic adjustment is 0.00025%.

I acknowledge that I have read and fully understand the information provided above and have had the opportunity to ask questions regarding its contents.

By signing below, I consent to the chiropractic procedures described above and understand that this consent applies to the entire course of care in this office.

Information referenced from: The National Center for Health Statistics, USA (1993); Risk Assessment for Cervical Manipulation vs. Non-Steroid Anti-Inflammatory Drugs for the Treatment of Neck Pain, JMPT, October 1995.

I understand and agree that I am financially responsible for all services and treatments provided by Richter Family Chiropractic.

In the event that payment is not made by any automobile insurance carrier, health insurance company, attorney, or other third-party payer, I understand that I remain personally responsible for the full balance of all charges for services rendered to myself or to any minor dependents for whom I am legally responsible.

If my account becomes past due and is referred to a collection agency or legal proceedings, I understand that I will be responsible for any additional costs incurred in collecting the debt. These costs may include, but are not limited to:

• Collection agency fees
• Court costs
• Filing fees
• Reasonable attorney fees where permitted by law

I acknowledge that I have been provided access to Richter Family Chiropractic’s Notice of Privacy Practices, which explains how my protected health information may be used or disclosed for purposes of treatment, payment, and healthcare operations as required by the Health Insurance Portability and Accountability Act (HIPAA).

I understand that I have the right to:

• Review the Notice of Privacy Practices
• Request restrictions on certain uses or disclosures of my health information
• Obtain a copy of my medical records as permitted by law
• Request confidential communication of my health information

I understand that this office reserves the right to update its privacy practices as permitted by law.