APPOINTMENT REMINDERS AND HEALTH CARE INFORMATION AUTHORIZATION

Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, inclement weather cancellations, information about care alternatives, or other health related information that may be of interest to you. If this contact is made by phone and you are not available, a message will be left by phone or with the person answering the phone.  We may also contact you by e-mail or text. By consenting to the terms of this agreement, you are giving us authorization to contact you with these reminders and information and to leave messages by phone or with individuals at your home or place of employment.

You may restrict the individuals or organizations to which your health care information is released or you my revoke your authorization to us at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone with access to the reminder or other information and may no longer be protected by the federal privacy rules.

You have the right to refuse to give us this authorization. If you do not give us authorization, it will not affect the care we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you to provide appointment reminders, information about care alternatives, or other health related information at any time.

This authorization will expire seven years after the date on which you last received services from us.

APPOINTMENT POLICY

Office visits are scheduled according to the severity of your condition and the program of care that the doctor feels is best for you. Because your condition requires numerous appointments over the next few months, we have designated a Multiple Appointment Program for your convenience. This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine.

The frequency of your visitation schedule is of paramount importance to your results, so we ask that each patient assume responsibility of adherence to the appointment program as it is designed for optimum results.

If for any reason, you are unable to keep your appointment, we require that you telephone immediately to reschedule that visit. It is the patient’s obligation to make up a missed appointment within 7 days of any cancellation. Also, this office reserves the right to charge for missed appointments and those appointments canceled without 24 hours’ notice.

We sincerely attempt to honor all appointments at the scheduled time. If you are late, you may be asked to wait for the next available appointment. We want to be respectful of your time, and put forth the utmost effort to run on time. Occasionally, unforeseen clinical circumstances may arise that cause us to run behind. If we are unexpectedly running behind, we will attempt to call you and advise you on the status of your appointment time. If you have any questions regarding our office policy or your appointments, please do not hesitate to ask.

CONSENT TO CHIROPRACTIC CARE

Chiropractic care is recognized as being an effective and safe method of care for many conditions. However, you must recognize that there are risks associated with all health care procedures which you should be informed about. All practitioners that adjust the spine are required to warn patients of material risks and seek informed consent for chiropractic care.

Chiropractic adjustments of the spine are internationally recognized as being far safer in dealing with neck and low back pain than medication and many other alternatives.

[A Risk Assessment of Cervical Manipulation, JMPT, 1994, Magna Report, Ontario Ministry of Health, 1993]

Please read the following carefully:

I acknowledge there are rare risks associated with my proposed care plan which include, but are not limited to, muscle strains, joint soreness, nausea and dizziness, fractures, disc injuries, strokes (or like episodes), and an exacerbation and/or aggravation of the underlying condition.

I have had the opportunity to discuss the proposed care plan with D M Dulmes, D.C. I also acknowledge that I have had the opportunity to ask questions about the nature, extent, and purpose of the proposed chiropractic care and that I have been given sufficient time to make a decision giving consent for the care to proceed. I acknowledge that I am aware of the potential risks. I appreciate that results are not guaranteed. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care plan. I hereby acknowledge my consent to the proposed chiropractic care plan by D M Dulmes, D.C., or any other chiropractor working in this clinic. I understand that I can withdraw consent at any time.

THIRD PARTY WEBSITE AND SOCIAL MEDIA POLICY

We are not responsible for any information collected by third party websites or email services on which we maintain a social media presence or send/receive emails. These include, but are not limited to, Facebook, Google, Twitter, Mailchimp. Each third party website has its own privacy policy and it should be read before creating an account and visiting any pages hosted by that service. We are not responsible for any marketing or retargeting performed by any other company after you have visited our Facebook Page, Twitter Page, etc.