Our office practices Subluxation-Based Chiropractic care. Subluxation Based Care care has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it.

Adjustment / Correction: A Subluxation Based Care Adjustment, or correction, is the specific application of forces to facilitate the body's correction of a vertebral subluxation. Our method of correction is by specific adjustments to the spine, with specific attention paid to the upper cervical area.

Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease, symptoms or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition. The only condition we address is the vertebral subluxation. However, if during the course of a spinal examination we encounter non-chiropractic or unusual findings, we will advise you.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjustments to correct vertebral subluxations.

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare options, and coordination of care.
2. The patient has the right to examine and obtain a copy of their own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI.
3. A patient's written consent need only be obtained one time for all subsequent care given in this office.
4. The patient may provide a written request to revoke consent at any time during care.
5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a compliance officer has been designated to enforce those procedures.
6. Patients have the right to file a formal complaint with our compliance officer about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I hereby request and consent to the performance of chiropractic adjustments, including diagnostic x-rays on myself (or on the patient named below for whom I am legally responsible) by the licensed Doctor of Rochet Family Chiropractic or any doctor who now or in the future works as a relief doctor.

I have had the opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and other procedures and understand that spinal adjusting involves the doctor placing his or her hands on my spine and delivering a quick thrust or impulse to the involved area(s).

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including but not limited to: fractures, disc injuries, strokes, dislocations, spasms, and soreness. I understand and comprehend all such risks and complications.

I authorize payment of insurance benefits directly to Rochet Family Chiropractic. I understand and agree to allow this office to use my Confidential Patient Health Information for the purpose of treatment, payment, healthcare operations and coordination of care.

I understand and agree that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand and agree that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment in this office.