Welcome to Arizona Chiropractic Neurology Center Patient and Contact Information History and Review of Systems
3800 W. Ray Rd. #12 Chandler, AZ 85226 Phone: (480) 756-2600 Fax: (480) 756-0800 Please fill out the following form in as much detail as possible. All your health information is kept confidential
List of current/previous doctors:
Medication List: Please list the name of each current prescribed and over the counter medications, prescribed use and any side effects/reactions
NEUROLOGICAL & METABOLIC CASE HISTORY
When was your last:
REVIEW OF SYSTEMS
Arizona Chiropractic Neurology Center
Informed Consent Document
To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.
The nature of the chiropractic adjustment
The primary treatment we use as a Doctor of Chiropractic is spinal manipulative therapy (SMT, CMT). We will use this procedure to treat you. We may use our hands or a mechanical instrument upon your body in such a way as you move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.
Analysis/Examination/Treatment
As part of the analysis, examination, and treatment, you are consenting to the following procedures:
--Spinal manipulative therapy --Palpation --Vital Signs
--Range of motion testing --Orthopedic testing --Neurological testing
--Postural analysis --EMS/TENS/Galvanic --Imaging and Lab studies as indicated
--hot/cold therapy --Stretching --massage therapy --exercise rehabilitation
--Microcurrent --low level laser therapy --SSEP --Functional medicine/supplements --Other____________
The material risks inherent in chiropractic care
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and physiotherapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strains, ligament sprains, cervical myelopathy, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke (CVA). Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. Cauda Equina Syndrome has been reported in rare cases which requires immediate medical care.
The probability of those risks occurring
Statistically, Chiropractic Care has been demonstrated to be one of the safest of all healthcare practices. Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the raking of your history and examination. CVA has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur one in five million cervical adjustments. Two major studies (2008, 2015) showed there was not causation between CMT and CVA but rather the patient was already presenting with arterial dissection. The other complications are also generally described as rare.
The availability and nature of other treatment options
Other treatment options for your condition may include:
-Self-administered, over-the-counter (OTC) analgesics, ice, head or rest.
-Medical care and prescription drugs such as anti-inflammatories, muscle relaxants and pain killers. -Hospitalization/Surgery
If you choose to use on of the above noted “other treatment” options, you should be aware that there are severe risks associated with these treatments. Many patients taking OTC NSAID’s such as Ibuprofen and Acetaminophen are not aware that every year there are thousands of deaths associated with their use. No medicine should ever be taken without discussing their side effects and inherent statistical danger with their primary care physician or pharmacist. The PDR is also a good reference regarding pharmaceutical use.
The risks and dangers attendant to remaining untreated
Remaining untreated may create adhesions or scar tissue that can weaken the area and reduce mobility. Further joint degeneration may occur as well as the development Dof chronic pain syndromes. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.
PATIENT FINANCIAL RESPONSIBILITY PATIENT RECORD OF DISCLOSURES/HIPAA ACKNOWLEDGEMENT
Thank you for choosing Arizona Chiropractic Neurology Center. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our Patient Financial Responsibility Policies and HIPPA Acknowledgment.
CANCELLATION/NO SHOW OF APPOINTMENTS: A 50% NON-REFUNDABLE
initial booking for all new patients. For all existing patients, failure to provide 24-hour advanced notification for cancellation or rescheduling existing visits is subject to a missed appointment fee. RETURNED CHECKS: There is a $25 service fee for any check returned for insufficient funds
PLEASE NOTE THAT ANY BENEFIT INFORMATION FURNISHED IS NOT A GUARANTEE OF PAYMENT NOR A DETERMINATION OF MEDICAL NECESSITY AND FINAL CLAIM DETERMINATION WILL BE MADE UPON RECEIPT AND REVIEW OF THE CLAIM.
THE PATIENT IS RESPONSIBLE FOR ALL BALANCES OUTSTANDING.
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
I wish to be contacted in the following manner (check all that apply):
I authorize the healthcare providers at Arizona Chiropractic Neurology to discuss my protected health information with the following family members or healthcare providers that are caring for me. I authorize the release of my medical health records from/to other healthcare providers that are caring for me.
I understand that I may revoke this authorization at any time, which will then apply to any future disclosures of my protected health information. I have been given the opportunity to review the Notice of Privacy Practices available in the office.