To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement.
Please read each point below.
I consent to a chiropractic spinal evaluation that the doctor deems necessary.
I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxations. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.
I acknowledge and understand that the only purpose for care in this office is in analyzing and adjusting for the removal of subluxation and the maintenance of health. I also understand that this office will NOT be Treating me for any condition or disease. Since I treat no conditions, I provide no releases from Work, School or for FMLA.
I acknowledge that this office & fee system are designed for life-time or Wellness care which Medicare does not pay for. I acknowledge that any Insurance(or Attorney's office) that I may have an agreement with is between me and that entity and that I am responsible for the payment of any and all services I receive at this office.
I grant permission to be contacted to confirm or reschedule an appointment and to be sent occasional cards, letters, text, eMails or health information to me as an extension of my care in this office.
To the best of my ability, all the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
I understand that I must attend at least one Office Introduction Workshop to continue care with this office beyond my 1st month.
Not Covered Under Program. This arrangement does not include extremity adjusting(other than the spine), massage, herbal products, emergency care, hours other than those available by Online Appointment. Extremity Adjusting should be scheduled independently from a regular office visit. Extremity adjusting is NOT part of our TRT protocol.
This Plan is Not Insurance. This agreement does not constitute insurance and as such Dr Rick Nash makes no commitment to care for anything other than a Spinal Subluxation under this agreement.
No Guarantee of Results. Client recognizes that this agreement is not a guarantee of clinical results, and that it deals solely with financial and time obligations. There is no guarantee that any illness, injury, or disease can be prevented or cured by participation in this program. Any balance due for services are due regardless of results.
If I am accepted as a practice partner/member of Sankofa Spinal Care. It is understood by all parties that this care is strictly for the identification, analysis and correction of vertebral subluxations, and does not include any attempt to diagnose, treat, cure or prevent any disease or condition, or offer advice or recommendations about disease conditions. Most insurance companies adhere to Medicare Guidelines which states that any care that seeks to prevent disease, promote health or prolong & enhance the quality of life are considered Not Medically necessary (MCM 2251.3). Care in this office is ONLY in analyzing and adjusting for the removal of spinal subluxations, promotion of health and enhancement of life.
I have read, agree to and accept all the Acknowledgements of this agreement.