Please indicate if a parent, child, or sibling has a history of the following:
Please check any present conditions that you have NOW or in the PAST.
If NONE, leave blank.
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
I, the undersigned, have voluntarily requested that the Doctors and/or other providers at Well Set assist me in the management of my health concerns. I understand and agree to all policies and terms provided in the office policies and producers.
As is the case with all health care interventions, the benefits of care must be weighed against the inherent risks and limitations of receiving treatment. Massage/manual therapy treatments are one of the safest interventions available to the public as evidenced by malpractice statistics. While there are risks involved with treatment, these are seldom great enough to contraindicate. A large part of our treatment involves manual therapy performed by hand or using instruments. Manual therapy is generally performed to increase range of motion, reduce scar tissue and/or treat sprains and strains. Some common side effects of manual therapy include soreness and bruising, and in rare cases exacerbation of the current complaint.
I understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I understand there is no certainty that I will achieve these benefits. I realize that the practice of medicine, as well as chiropractic/PT/massage, has limitations and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the procedures by my doctor/provider and such other persons of the doctor’s choosing.
One research study indicated that within the first 2 months of care, approximately half of the patients reported some “reaction” to treatment. Of those who reported a reaction, the following were the most commonly reported reactions to initial care (most commonly chiropractic/PT):
*Most appeared within 4 hours of treatment and resolved within 24 hours.
Reasonable alternatives to these procedures include but are not limited to:
Please answer the following questions below by checking YES or NO. These questions help us determine possible risk factors:
A thorough health history review and possible physical examination will be performed on me to minimize the risk of any complications from treatment, and I freely assume these risks. I have read (or have had read to me) the above explanation of chiropractic treatment. The doctor/provider has also asked me if I want a 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. To attest to my consent to these examinations and treatment procedures, I hereby affix my signature to this informed consent document.
Well Set is an out-of-network provider with all health insurance companies. It is your responsibility to verify if you have out-of-network benefits before your first appointment. If needed, Well Set can teach you how to check your out-of-network benefits. Payment is due at the time of service. If I choose to use my out-of-network benefit, I authorize and request my insurance company to pay directly to Well Set, the insurance benefits that are otherwise payable to me. I understand that my chiropractic insurance carrier may cover only a portion of, or not cover all of the services rendered. I agree to be ultimately responsible for all costs for services rendered and that they are payable when services are rendered.
We require a minimum of 24-hours notice to cancel or reschedule all new patient chiropractic appointments and for all PT and massage appointments (new and follow-up). We also require at least 2 business hours notice before follow-up chiropractic appointments. To better serve all of our patients and ensure that they have a fair opportunity to have an appointment as promptly as possible, please observe our cancellation policy for all appointments.
No shows / late cancels will be billed at half the price for the first missed appointment for all massage appointments, chiropractic, and PT, and full price for any subsequent missed appointments.
All prepaid packages for massage are non-refundable. These packages include a discounted rate for service, and the balance of the package must be used for massage. There are no refunds for any services rendered.
I understand that I may request and review the privacy practice for Well Set and understand the situations in which this practice may need to utilize or release my medical records. I also understand that I agreed to the use of those when I initiated care at this office on my first visit, whenever that may have occurred.
I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this privacy practices statement.
I authorize the doctor to release any information including the diagnosis and the records of treatment or examination rendered to me or my dependent during the period of such chiropractic care to third party payers and/or health practitioners. I allow the providers and staff at Well Set to discuss my treatment and diagnosis with the following doctors, health care professionals, coaches, lawyers, spouses, etc. :
email@example.com W. 29th Avenue, Suite 203 Denver, CO 80212
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