Download Surgical Alternatives * Consent to Treatment / Financial Agreement

Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
CONSENT TO TREATMENT / FINANCIAL AGREEMENT
Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and benefits of the
treatment, and any alternatives to the treatment provided. There are some inherent risks that may be associated with chiropractic
treatments, acupuncture treatments, non-surgical bunion therapy, and non-surgical face-lifts, including, but not limited to:

Aggravation of pre-existing symptoms

Allergic reactions to supplements or herbs

Rib fractures or muscle and ligament sprains or strains following treatment.

Disc injuries following cervical and lumbar spinal adjustment (although no scientific study demonstrates such injuries
are caused, or may be caused, by spinal or soft tissue manipulation or treatment).

Vertebral artery injury following osseous spinal manipulation. Vertebral artery injuries have been known to cause a
stroke, sometimes with serious neurological impairment, and may, on rare occasion, result in paralysis or death. The
possibility of such injuries resulting from cervical spine manipulation is extremely remote.

Pain, Bruising, or swelling associated with bunion therapy especially at the calf, ankle, and foot.

Some skin reaction to topical analgesic solution used in the bunion procedure therapy to help relieve joint pain.
Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies conducted over
many years and have demonstrated it to be highly effective treatment of spinal conditions including general pain and loss of
mobility, headaches and other related symptoms. Musculoskeletal care contributes to your overall well-being. The risk of injuries
or complications from treatment is substantially lower than that associated with many medical or other treatments, medications,
and procedures given for the same symptoms.
________ I acknowledge I will have the opportunity to discuss the following with my healthcare provider:
a. The condition that the treatment is to address;
b. The nature of the treatment;
c. The risks and benefits of that treatment; and
d. Any alternatives to that treatment
I voluntarily consent to outpatient care at Surgical Alternatives, encompassing routine diagnostic procedures, examination and
treatment including, but not limited to, chiropractic adjustments, acupuncture therapy, non-surgical bunion therapy, non-surgical
face-lifts, and chronic pain relief treatments.
I further consent to the performance of these diagnostic procedures, examinations and rendering of treatment by the staff. I
understand that some treatments are considered experimental and that some treatment or suggestions provided are NOT accepted
by the United States FDA. I therefore, hereby release Dr. Robert Levingston, D.C., FIAMA from any liability arriving out of the
status of the approval or lack of approval of these therapeutic procedures.
I agree to inform Dr. Levingston immediately of any disease process that I am suffering from, or if I am on any medication or over
the counter drugs; (If you are pregnant or you are breast-feeding please advise Dr. Levingston immediately).
________ I understand that a record will be kept of the health services provided to me. This record will be kept confidential and
will not be released to others without my consent, unless required by law. I understand that I may look at my medical record at any
time and can request a copy of it by paying the appropriate fee.
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
________ I understand that Dr. Levingston will answer my questions that I have to the best of his ability. I do not expect the doctor
to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the
course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.
I understand that bunion therapy is not a substitute for surgery but merely a treatment involving strengthening the muscles of the
foot (particularly the abductor hallicus) as an attempt to help correct the hallux valgus deformity and reposition the misaligned big
toe where the bunions is located. As in all healthcare cases, in regards to bunion therapy, results may vary and there is no
guarantee that one patient will have the same result as another.
I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved
mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I
realize that the practice of medicine, including chiropractic and bunion therapy, is not an exact science and I acknowledge that no
guarantee has been made to me regarding that outcome of these procedures.
I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and soft tissue
manipulation and bunion therapy. I intend this consent to apply to all my present and future care with Dr. Levingston or other
licensed doctors of chiropractic who now, or in the future, treat me while employed by, working for or serving as back-up for Dr.
Levingston, D.C., FIAMA.
_________ I understand that all charges are to be paid at the time of the visit. Payments for all dispensary items such as
supplements, serums, or solutions are due at the time of the visit.
I understand and agree that as the patient, I am responsible for the total charges incurred for each visit including costs of
supplements. I understand that most insurance companies do not cover the cost of alternative therapies or supplements. I have
read and understood the above stated policies and information. I intend this consent form to cover the entire course of treatment(s)
for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures
at any time.
______________________________
Signature of Patient
______________________________
Name of Patient (Printed)
_________________
Date Signed
______________________________
Signature of Legal Representative
(e.g. attorney-in-fact, guardian, parent if minor)
______________________________
Relationship
_________________
Date Signed
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT
TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS
I, ______________________________________ hereby state that by signing this Consent, I acknowledge and agree as follows:
(Printed Name)
1.
The Practice’s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a
complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for the Practice to
provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health
care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The
Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged
me to read the Privacy Notice carefully prior to my signing this Consent.
2.
The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with
applicable law.
3.
I understand that, and consent to, the following appointment reminders that may be used by the Practice: a) a postcard mailed
to me at the address provided by me; b) telephoning my phone and leaving a message on my answering machine or with the
individual answering the phone; c) e-mail sent to the e-mail address provided by me; and d) text message sent to my mobile
device capable of receiving text messages after receiving notice that I prefer this type of notification. I understand that standard
text rates may apply from my mobile service provider.
4.
The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment
provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice
to conduct its specific health care operations.
5.
I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment,
payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested.
If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.
6.
I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in
writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent
that the Practice has already taken action in reliance on this consent.
7.
I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.
8.
I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and
contained in the Privacy Notice, then the Practice will not treat me.
I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a
way that I can understand.
______________________________
Signature of Individual
______________________________
Name of Individual (Printed)
__________________
Date Signed
______________________________
Signature of Legal Representative
(e.g. attorney-in-fact, guardian, parent if minor)
______________________________
Relationship
_________________
Date signed
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
Non-Surgical
Bunion
Treatment
Guidelines
Patient Name: _________________________________
Date:
__________________
(Please Print)
Please read and initial next to each line. By initialing next to each line, you are indicating that you understand and agree to adhere
to the following Bunion Treatment guidelines:
______ I agree to perform my exercises and/or walking re-education, as instructed by Dr. Levingston, for a minimum of
20minutes per day (10 solid minutes each set) for the duration of my 10-session bunion treatment.
______ I agree to limit and/or abstain from drinking alcohol or coffee during duration of the treatment period.
______ I will continue to perform my instructed exercises at home as a form of maintenance post bunion treatment to
continue to strengthen and maintain my Hallux Valgus correction attained from the treatment with Dr.
Levingston.
______ I agree not to wear tight fitting shoes, high heels, or sandals for the duration of my 10-session bunion
treatment. I understand that not following this guideline could prevent me from receiving the full benefit of
my
bunion therapy and prevent me from meeting my intended goals.
______ I agree to limit tight fitting shoes, high heels, or sandals post bunion treatment. I understand that not
following
this guideline could potentially reverse any Hallux Valgus correction attained during my bunion
treatment.
______ I agree to stay hydrated by drinking the recommended amount of water:
Recommended Daily Water Intake: ______ Ounces / ______ glasses of water
Patient Signature: ________________________________
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
New Patient Intake Form
Today’s Date: ____/____/______
Patient Name: __________________________________________ Date of Birth: ______/______/_______ Age: __________
Address __________________________________________ City _________________ State ______ Zip Code ____________
Home Phone: ____________________
Work Phone: _____________________
Email: _____________________________________ Sex:
Employment Status:
Employed
Unemployed
Male
Female
FT Student
Cell Phone: _____________________
Marital Status:
PT Student
Single
Married
Other____________________
Employer Name: ____________________________________ Occupation: _________________________________________
Employer Address ____________________________________ City ____________________ State_____ Zip Code _________
Primary Care Physician ___________________________________ Phone #: _________________ Last Visit _____________
Emergency Contact Name: _________________________________ Relationship to Patient: __________________________
Emergency Contact Phone #: ____________________________
Reason for Visit:
Chiropractic
I will be paying by:
Non-Surgical Bunion Repair
Hair Renewal
Other: ___________________________
Cash
Alternative phone: ______________________________
Non-Surgical Facelift
Acupuncture
How did you hear about us? __________________________
Credit / Debit card
I have completed and reviewed the above information and to the best of my knowledge it is accurate. I authorize the individual
physicians to advise me of any necessary procedures, diagnostic studies and treatment. I will notify you of any changes in my
status of the above information.
Patient Signature:
(Patient or Parental Signature if Patient is a Minor)
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
Date:
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
Medical Conditions (Check all that apply):
Arthritis
Hypertension
Headaches
Urinary
Cancer
Psychiatric Illness
Multiple Sclerosis
Ears, Nose, Throat
Diabetes
Skin Disorder
Epilepsy
Back
Heart Disease
Stroke
GI
Neck
Other: _________________________________________________________________________
Past Medical History: ______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Surgeries (Please list ALL surgeries and hospitalizations): _________________________________________________________
________________________________________________________________________________________________________
Allergies: ________________________________________________________________________________________________
Social History (Check all that apply):
Caffeine use:
Drink Alcohol:
Exercise:
Cigarettes:
Occasional
Occasional
Occasional
<1 pack/day
Often
Often
Often
>1 pack/day
Never
Never
Never
Never
Family History (Check all that apply):
Arthritis:
Cancer:
Diabetes:
Heart Disease:
Hypertension:
Stroke:
Thyroid:
Parent
Parent
Parent
Parent
Parent
Parent
Parent
Sibling
Sibling
Sibling
Sibling
Sibling
Sibling
Sibling
Other: ___________________________________________________________________________
Current Medication/Vitamins: _______________________________________________________________________________
_______________________________________________________________________________________________________
Are you pregnant?
Yes ______
NO _______
N/A ________
The statements on this form are correct to the best of my recollection. I understand that I am financially responsible for all charges. I
understand that Dr. Levingston dos not bill insurance and payment is due at the time of service.
Patient Signature: ______________________________________
Surgical Alternatives
Date: ____________________________
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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Surgical Alternatives – Consent to Treatment / Financial Agreement
Dr. Robert Levingston, D.C., FIAMA
BUNION QUESTIONNAIRE
Patient Name: ______________________________
Date: __________________
Please answer the following questions with as much detail as possible:
How long have you been suffering from bunions?
Do your bunions make it difficult and/or painful to walk?
Do you believe your bunions are causing you to have foot and/or back pain?
Do your bunions prevent you from fun activities or exercising?
Do you feel that your bunions are causing your feet to look deformed or unattractive?
Are you self-conscious about showing your feet in public?
Is it hard to find shoes that fit?
Surgical Alternatives
3470 S. Sherman St., Ste. 3, Englewood, CO
(303) 532-4844
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