Informed Consent Financial Policy Form


Informed Consent
The information I have provided, on this history form, is true and accurate, to the best of my knowledge. I give Dr Alex and Dr Tiffany permission to render care to me today. This initial visit includes a health history/consultation, chiropractic examination, x-rays (if warranted) and any initial care that is determined to be clinically necessary and mutually agreed upon.

Signature

Date

Authorization to Treat a Minor
The information I have provided, on this history form, is true and accurate, to the best of my knowledge. I give Dr Alex and Dr Tiffany permission to render care to my child today. This initial visit includes a health history/consultation, chiropractic examination, x-rays (if warranted) and any initial care that is determined to be clinically necessary and mutually agreed upon.

Signature of Parent (for minor)

Date

Financial Policy
Your insurance is an agreement between you and your insurance company. Insurance coverage varies greatly and we cannot be certain that your policy will cover the services we provided in our office. It is to be understood and agreed that all services rendered to you and your family are your personal responsibility and you are personally responsible for payment of any non-covered services, deductibles, co-pays and co-insurance. Please indicate below your primary and secondary methods of payment:

Primary method of Payment:

Secondary method of Payment:

I have read and understand the above policy. I have checked the one that applies to me.

Name

Date

Thank you for choosing Healthy Start Chiropractic & Wellness.
We look forward to helping you and your family achieve your health goals!

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