At what age did your child:

Please check the corresponding boxes for each symptom or condition your child has experienced - including both past and present

Informed Consent

Chiropractic, like other types of health care, is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risk related to your care before consenting to treatment. Chiropractic care may be accompanied by post treatment soreness. Chiropractic treatment may aggravate a disc injury, or cause other minor joint, ligament, tendon, or other soft tissue injury. Manual adjustments to the thoracic spine, in rare cases, may cause rib injury or fracture. Precautions such as pre-adjustment testing and evaluations are performed to minimize risk. Heat generated by physical therapy modalities may cause minor burns to the skin. Extremely rare but more serious side effects such as stroke or even death may occur. A study in the Journal of the CCA (Vol 37, no 2, June ‘93) estimates the incident of stroke as 1 in 3,000,000 (three million) upper cervical adjustments. All side effects associated with chiropractic are rare and should be reported to your doctor of chiropractic promptly.
Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition or disease as a result of treatment. An attempt to provide you the very best care is our goal and if the results are not acceptable, we will refer you to another provider who we feel will assist you in your situation. If you have any questions concerning the above, please ask your doctor of chiropractic. Having carefully read the above, I hereby give my informed consent to have chiropractic treatment administered.

Notice of Privacy Policy

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent.

• You may request restrictions on your disclosures
• You may inspect and receive copies of your records within 30 days of a request
• You may request to view changes to your records

I understand that under the Health Insurance Portability & accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly.
• Obtain payment from third party payers
• Conduct normal healthcare operations such as quality assessments and physicians’ certifications.

I have read and understand the Notice of Privacy Policy. A more complete description can be requested. I also understand that I can request in writing, that you restrict how my personal informaiton is used and or disclosed.

Personal Health Information (PHI) Conditional Release

Blue Hills Chiropractic has a strong focus on public education and interaction. I understand that occasionally Blue Hills Chiropractic will use photo, video, or other likenesses of myself and family for promotion of chiropractic education and the clinic. I release Blue Hills Chiropractic LLC and its employees of all legal liabilities and authorize them to use photos, videos, and/or likenesses of myself and family for education and/or advertising purposes. I give permission for Blue Hills Chiropractic to contact me by phone, sms, email, and via social media in order to schedule care, share information about the clinic and promotions, or any other relevant business or medical need. I understand that these types of communication are not encrypted end-to-end and are at a higher risk of a third party viewing them. I understand I may opt out of a specific promotion or method of contact at any time, but it does not retract my consent from all other promotions and contact methods. I may rescind this authorization at any time by contacting Blue Hills Chiropractic in writing.

I have read and understand the above Informed Consent, Notice of Privacy Policy, and Personal Health Information Conditional Release, and agree to the terms stated as indicated by my initials. In the event any provision or part of this Agreement is found to be invalid or unenforceable, only that particular provision or part so found, and not the entire Agreement, will be inoperative.