Consent Form

We are required by law to provide you with our Notice of Privacy Practices, which explains how we use and disclose your health information. We are also required to obtain your signature acknowledging that this notice has been made available to you. As noted in our Notice of Privacy Practices, by signing below you understand that our email and fax are a non-secured means of sharing patient information. Your patient information will not be shared through email or fax unless you have requested us to do so. You also understand that any emails or faxes you send directly to us are through a non-secured source.

Performance Rehab Associates are not permitted, by law, to provide information to anyone other than the patient regarding treatment, payment. and healthcare operations as described in the Performance Rehab Associates Notice of Privacy Practices.

The staff at Performance Rehab Associates would like to know with whom, if anyone, you want us to be able to discuss your treatment, instructions for treatment, treatment plans, condition updates, lab results, and appointment information. This would also include leaving a message on your answering machine, voicemail, and/or sending and responding to emails through a non- secured source.

I authorize the release of my medical information regarding my treatment and care to the following individuals upon their request:

Please read this entire document prior to signing it. It is very important that you understand the information contained in this document. If anything is unclear, please ask questions before you sign.

The nature of the chiropractic adjustment

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I may use this procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click" due to the release of gas within the joint fluid, much as you have experienced when you "crack" your knuckles. You may feel a sense of movement.

The material risks inherent in chiropractic adjustment.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, and costovertebral strains and separations. Manipulation of the neck may be associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients may feel some stiffness and soreness following the first few days of treatment. History and physical examination help to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which is screened for during the taking of your history and during examination. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The risks and dangers attendant if remained untreated.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Advanced arthritic changes are usually the result of reduced segmental mobility and adaptive changes.

I hereby request and consent to the performance of the proposed treatment plan which may include chiropractic manipulation, therapeutic procedures and various modes of physical therapy (patient named below, for whom I am legally responsible) by the licensed chiropractic physician name above and/or other licensed provider who currently work at the clinic listed above.

I understand and have been informed that there maybe some risks associated with chiropractic manipulation, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications of treatment. I will rely upon the doctor to exercise good medical judgment during the course of procedures.

I have read or have had read to me the above consent. I have also had an opportunity to ask questions about its consent, and by signing below I agree to the above-named procedures. I intend this consent form to cover all treatment for my present condition and for any future condition(s) for which I seek treatme

Physical therapy involves the use of many different types of physical evaluation and treatment. At Performance Rehab Associates we use a variety of procedures and modalities to help us to try to improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy.

Since the physical response to a specific treatment can vary widely from person to person, it is hot always possible to accurately predict your response to a certain therapy modality or procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury or may aggravate previously existing conditions.

You have the right to ask your physical therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms, and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of our treatment at any time before or during your treatment session.

Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them.

Please initial that you have read and agree to the following statements:

I consent to physical therapy services at Performance Rehab Associates. I know if I have any questions about my care, I should be sure to ask the physical therapist about them. I know it is up to me to inform the physical therapist/staff about any health problems or allergies I have. I must also tell the physical therapist/staff about drugs or medications I am taking

I understand that the practice of physical therapy is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist or supportive personnel. I understand that no contract, warranty, guarantee, or promise concerning the results of the physical therapy services is made. This consent to treatment form is not a contract, nor is it an offer to contract, nor is it an acceptance of an offer to contract.

I understand that if I arrive 10 minutes or later for my appointment, my therapist may not have time to treat me or my therapy time may be reduced.

As part of your treatment plan your provider recommends the services shown below which are marked with an asterisk (*), and has confirmed that these services are not covered by your healthcare plan.

• Kinesio/Supportive Taping $5-20

• Microcurrent (FSM) $65

• Electrical Stimulation $65

• Shockwave Therapy* $65

• Acupuncture* $65

• Dry Needling* $65

• Cold Laser* $20

• PEMF $65

• Alter G $40

• Thera-Bands/Loop Bands $5

Additionally, your provider may also recommend certain CPT Codes as part of your treatment plan, there is no guarantee of payment/coverage by your healthcare plan until the claims have processed in full. Since these services may not be covered by your healthcare plan, the purpose of this notice is to help you make an informed decision about whether you want to receive these items/services. By signing below, you specifically indicate your understanding that these services may not be covered by your healthcare plan. Further, your signature indicates you have chosen to receive these non-covered services and to pay in full for the services.

By completing the above information, you hereby authorize Performance Rehab Associates to debit the credit card left on file. You will be charged for services rendered at the time of your visit including co- payments, deductible and/or coinsurance amounts, cost of non-covered services (see non-covered waiver), supply purchases, and any fees associated with missed appointments (see non-covered waiver). Your card will be charged $80.00 if you do not cancel your appointment with proper notification within 24 business hours and/or 3 or more cancelled appointments in a row.

Emergency situations are exempted from this charge. You agree that each charge to your credit card shall be the same as if you had processed your payment in person. Your credit card will be charged the day of or the day after your scheduled appointment. You agree that no prior notification will be provided for charges unless otherwise requested by the card holder to the practice manager by emailing admin@pracharlotte.com.

​​​​​​​If prior notification is requested, you will receive an email notice from us by 5pm the same day of your scheduled appointment and payments will still be processed the day or or the day after your scheduled appointment. Should there be an error with processing your payment, you will receive a call from 980.819.8020 to obtain alternate credit card information. Should you have a change in credit card information, it is your responsibility to notify Performance Rehab Associates and provide a new version of this form with current and accurate information. It is your responsibility to contact the practice manager should you have any questions regarding this process. By signing below, you understand and agree with all the information you have read.