PRACTICE POLICIES AND INFORMED CONSENT
Hello and welcome to Dallas Sports Academy. Please take the time to read our policies. If you have any questions please do not hesitate to ask. We look forward to working together to help you regain, maintain, and reach optimal health.
Your appointment time is reserved for only you. Our practice DOES NOT double book appointments. 24 hours notice is required should you need to cancel an appointment. You will be charged the full fee of your office visit should you fail to give 24 hours notice. It is important that you be on time for your appointment. If you are late, we will make every effort to see you, but it may not always be possible. Your will still be responsible for your appointment fee if you are late.
1. Payment is due at the time services are rendered. We accept cash, Visa/MasterCard, or a personal check.
2. A $30 reprocessing fee will be charged to your account should any personal check fail to clear.
TEXT AND EMAIL CONSENT
I do hereby authorize Dallas Sports Academy, Steven M. Horwitz, D.C. to communicate with me via text and email at the phone/text number and email address I have provided on my intake forms
This office transmits patient protected health information electronically.
INFORMED CONSENT FOR CHIROPRACTIC TREATMENT
TO THE PATIENT: You have a right to be informed about your condition, the recommended chiropractic treatment, and the potential risks involved with the recommended treatment. This information will assist you in making an informed decision whether or not to have the treatment. This information is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or refuse to give your consent to treatment.
I request and consent to chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays. The chiropractic treatment may be performed by Steven M. Horwitz, D.C. and/or other licensed Doctors of Chiropractic working at this clinic or office. Chiropractic treatment may also be performed by a Doctor of Chiropractic who is serving as a backup for Steven M. Horwitz, D.C.
I have had the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of my chiropractic treatment, the risks and benefits of my chiropractic treatment, alternatives to my chiropractic treatment, and the risks and benefits of alternative treatment, including no treatment at all.
I understand that, there are some risks to chiropractic treatment including, but not limited to:
Burns or frostbite (physical therapy)
Worsening/aggravation of spinal conditions
Increased symptoms and pain
No improvement of symptoms or pain
Punctured lung (acupuncture)
In rare cases there have been reported complications of vertebral artery dissection (stroke) when a patient receives a cervical adjustment. The complications reported can include temporary minor dizziness, nausea, paralysis, vision loss, locked in syndrome (complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement), and death.
I do not expect the doctor to be able to anticipate and explain all risks and complications. I also understand that no guarantees or promises have been made to me concerning the results expected from the treatment.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions. All of my questions have been answered to my satisfaction. I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my current condition.