HIPAA ACKNOWLEDGEMENT
I give Dr. Marie Ouellette, D.C., associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) permission to speak with the following people in regard to my care, appointments, insurance, billing, test results, claims, etc.
CONSENT TO TREATMENT
I give my consent to Dr. Marie Ouellette, D.C., associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) to perform any and all examinations, tests, treatment, physical therapy and other reasonable measures it deems necessary to diagnose and treat my condition. My signature at the bottom of this document affirms I understand and do not have any questions on all of the statements made above.
TEXT/EMAIL/SOCIAL MEDIA​
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I give Dr. Marie Ouellette, D.C., associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) permission to text and/or email me for the purpose of appointment reminders and special events. Special messages, events or promotions will be emailed and limited to 2 (two) per month.
I give Dr. Marie Ouellette, D.C., associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) permission to take pictures and/or videos for the purpose of marketing and social media. My signature at the bottom of this document affirms this.
PATIENT X-RAY WAIVER-RELEASE AND INDEMNIFICATION
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This form will confirm that Marie Ouellette, D.C. associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) has recommended that I undergo spinal X-rays in connection with my chiropractic evaluation and treatment of my condition.
In recognition of this voluntary waiver, I, as the undersigned patient, and for or on behalf of my minor child (who may be subject to chiropractic treatment) hereby release and forever discharge and hold harmless; on behalf of myself, my heirs, representatives, executors, administrators, and assigns Marie Ouellette, D.C. associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic), including its officers, agents, assigns, employees, and legal representatives, from any and all responsibility, liability, causes of action, claim, or demand, or any nature whatsoever, including, but not limited to, a claim of negligencethat may arise out of or relate in any manner to the evaluation of my present condition or resulting chiropractic care and adjustments which my doctor may be unable to fully or properly analyze without the benefit of taking my X-rays. This release is to be broadly interpreted to extend to consequential property damage, and personal injury, including death. As such, I specifically give and authorize consent to Marie Ouellette, D.C. associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic) to administer chiropractic treatment which is analyzed from a chiropractic treatment prospective for treatment of my condition, without the benefit of submitting to such X-rays.
I further agree to indemnify and hold harmless Marie Ouellette, D.C. associated with Dr. Marie Ouellette, LLC (dba The Old Village Chiropractic), its officers, agents, employees and assigns, from any and all causes of action, claims, demands, loss of any nature whatsoever arising out of or in any way related to the chiropractic evaluation and treatment of my condition without submitting to having X-rays taken.
I hereby certify and attest that this release/waiver and agreement to indemnify and hold harmless is given freely, knowingly, and voluntarily. I further understand and acknowledge that by signing this form, I am signing a legally binding agreement which I may be waiving certain legal rights to recover compensation or obtain other remedies for injury to property and myself, including death, which I may have in the event that such injury or complication should occur as a proximate result of this waiver of my submissions to X-rays, now or at any time in the future. I chose to sign this waiver fully knowing that my health may be jeopardized due to this decision.
DRY NEEDLING INFORMED CONSENT
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Please review the following information PRIOR to consenting to application of dry needling techniques which is recommended by my office as part of your plan of care. Dry needling is not acupuncture. However, it is a technique that utilizes thin solid filament needles. This needling technique is used to specifically treat myofascial trigger points, muscle spasms, or dysfunctional tissue. Like any medical procedure, there are possible complications. While these complications are uncommon, they do sometimes occur and must be considered prior to giving consent to the procedure:
Pain. When a needle is inserted in the correct location, it may briefly reproduce a muscular ache or a twitching response which indicates the technique should be effective in reducing the symptom. You may experience a muscular ache for one or two days followed by an unexpected improvement of your overall symptoms. It is extremely important that your doctor is made aware if you are feeling uncomfortable with the treatment.
Infection. Any form of skin penetration creates an opportunity for bacteria to enter the system. In order to minimize the risk, your doctor will follow the proper disinfection procedures and will use only the sterile disposable single-use needles.
Brusing or Bleeding. On occasion you may experience a small painless bruise or blood spotting in the treated region. Bruising and the blood spotting of this nature would clear very quickly.
Drowsiness, fatigue and autonomic responses. On occaision you may experience a feeling of tiredness, nausea, dizziness, sweating: if this occurs, you will be asked to avoid driving until the feeling has passed. Change in blood pressure, heart rate, flushing of the face or breathing rate are involuntary reflexes which may change temporarily as a result of dry needling; these occur rarely and should give no cause for concern.
Pneumothorax. There have been approximately 100 reported cases worldwide of acupuncture needles puncturing a lung. This only occurs when needles are insterted too deeply or incorrectly. Pneumothorax is a serious medical condition requiring admission to a hospital. Your doctor has been trained to avoid the lungs and limit the needle depth to avoid this occurring.
Indicate below if you have any of the following conditions:
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I have read this form and I understand the risks involved with dry needling therapy. I have had the opportunity to ask questions and express any concerns, of which have been answered to my satisfaction. I also agree to advise my Chiropractor of any and all changes in my physical condition whether or not I believe these changes will affect my treatment or plan of care. My signature at the bottom of this forms affirms that I consent to dry needling treatment provided by my Chiropractor.
TERMS OF ACCEPTANCE
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You are the decision maker for your health care. Part of our role is to provide you with information to empower you to make informed choices. The process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.
We may conduct some diagnostic examination procedures if indicated. Any examinations or tests conducted will be carefully performed by may be uncomfortable.
Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional procedures or recommendations, as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include, but not limited to, restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.
It is important that you understand, as with all health care approaches, results are not guaranteed and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs & ice, fractures (broken bones), disc injuries, strokes, dislocations, strains & sprains, paralysis (partial and/or full) and death. With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot with the potential to lead to a stroke). The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection within a normal, healthy artery. Disease process, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.
Arterial dissections occur in 3-4 of every 100,000 people, whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke.
The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.
It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already.
These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures & rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.
I have read, or have had it read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendations to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.
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FINANCIAL POLICY
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We will be happy to discuss this policy and fees at any time. Payment for services is due at the time services are rendered. This includes any deductible, coinsurance, copayment, non-covered services, or uninsured patients. We accept cash and credit cards, debit cards and most HRA/HSA cards. Checks are not accepted.
Your insurance policy is a contract between you, your employer and/or the insurance carrier. We are not a party in that contract. We will file a claim with your insurance carrier for our contracted plans. If you have a dispute regarding a deductible, coinsurance, copayment, covered/non-covered services, or the allowed amount by your insurance carrier, you have to contact them directly. We will try to assist you if we can.
All denied charges are your responsibility if your insurance carrier does not pay. Not all services rendered are a covered benefit. We will do our best to verify which services and how many are covered, as well as any deductible, coinsurance or copayment you may have. Your carrier can change at any time without any notification to us. It is your responsibility to notify us of any change or termination of your policy.
If an insurance payment results in an overpayment on your account, this will automatically be credited to the next visit. If you wish to request a refund, please notify the Office Manager.
We understand that a temporary financial issue may arise. We do not want this to affect your care or the reason you cancel appointments. Please contact the Office Manager so that a payment arrangement can be made.
I understand that if my account has an unpaid balance, my account is at risk for being sent to collections and I will incur a 2% interest rate compounded monthly and that I will be required to pay attorney and collection fees.
In order to give you and all our patients the best care possible, we will charge for any appointments not cancelled within 24 hours. Cancelling an appointment allows for us to offer that time to another patient. If you arrive 15 minutes past your appointment time, you will be charged a missed appointment fee. This fee is not covered by your insurance carrier.
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I understand that I must CALL the office 24 hours prior to cancel appointments.
I understand the missed appointment fee is $50.00
