Your Partners In Health

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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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