CHIROPRACTIC INFORMED CONSENT (For Chiropractic Patients ONLY)
Dr. Paul's goal is to provide you with adjunctive and supportive care for your health condition. We do not claim to treat or cure any disease or medical diagnosis.
Our office does not take insurance. However, a superbill may be printed out for you, so you can send it to your insurance. Most services at our office are not covered by insurance. These services are considered experimental and may not be billed to your insurance. Nutritional support may be offered for your case. Nutritional supplements are not FDA regulated and have not been proven to cure or treat any disease or illness.
Our services are not a replacement for your medical treatment. We choose to work alongside your medical provider as this serves you in the most effective manner possible.
Dr. Kwik will never give advice on the use of your medications. Medications must be managed by your medical doctor. You must work with a medical doctor for the management of any medications you take now or in the future.
I completely understand that there are no guarantees of help, correction, relief, or cure, written, spoken or implied. I understand that this clinic does NOT treat any disease or any medical diagnosis.
I am making a sane and conscious decision to seek advice as per the above understood terms for either myself and/or my dependents. In doing so, I agree to the above terms and acknowledge this with my signature below:
If agreed upon between Body Intelligent Center and myself, I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination test, diagnostic x-ray(s) and physical therapy techniques, on me (or on the patient named below for which I am legally responsible) which are recommended by the Body Intelligent Center.
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 and sprains. It is not reasonable to expect the doctor to be able to anticipate and explain all risks and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.
I have read, or have had read to me, the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment or my present condition and for any future condition(s) for which I seek treatment.
NUTRITIONAL INFORMED CONSENT (For All Patients)
According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean:
“Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.”
A Vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.
Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented or be classified as a drug by anyone.
Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.
Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.
Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments and treatment.
Ideal Protein Clients ONLY
I confirm that the information that I have provided and that is recorded by me on the “Ideal Protein" Health Profile is true, complete and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status. In this respect, I confirm that I have disclosed all past and present i) physical and/or mental health problems or concerns that I have experienced, ii) diagnoses and/or surgeries that I have had, and iii) medications and supplements that were prescribed to me or that I have taken.
Without limitation to the foregoing, I specifically confirm that I do not have any of the conditions and that I am not taking any of the medications specifically discussed on intake forms in drkwik.com. Furthermore, I understand that I should not be undertaking or otherwise following the “Ideal Protein" Weight Loss Method if I have any of the said conditions or if I am currently taking any of the said medications unless i) I specifically consult with a medical doctor concerning my suitability to go on the “Ideal Protein" Weight Loss Method, ii) remain under the supervision of said medical doctor while I am on the “Ideal Protein" Weight Loss Method, and iii) provide documentation confirming the foregoing.
I understand that if i) I have any of the aforementioned conditions or if I am currently taking any of the aforementioned medication, ii) have not disclosed same to the clinic and iii) nevertheless chose to go on the “Ideal Protein" Weight Loss Method without specific supervision, such decision will be completely voluntary, and I release and discharge the clinic as well as Ideal Protein of America, its parent companies, subsidiaries and affiliates and their respective shareholders, directors, employees, agents, representatives, successors and assigns (collectively, the "Releases") from any and all damages, liability, claims and causes of action of any nature whatsoever (including for injury, illness or death) that may result from such voluntary and informed decision.
I confirm that the “Ideal Protein" Weight Loss Method has been explained to me, that I have had the opportunity to ask questions relating to the “Ideal Protein" Weight Loss Method, that I have been provided with the answers to such questions and that I understand the importance of strictly following the “Ideal Protein" Weight Loss Method as explained to me verbally and in the materials provided to me, both before and during the period I will be following the “Ideal Protein" Weight Loss Method.
Without limitation to the foregoing, I confirm that I have been advised that because the “Ideal Protein" Weight Loss Method limits the ingestion of certain foods, it is important that I consume the recommended vitamins and minerals while I am on the “Ideal Protein" Weight Loss Method.
I undertake to disclose immediately to the clinic any and all changes in my health status, discomfort, symptoms or other health concerns that I may experience while I am on the “Ideal Protein" Weight Loss Method.
Agreement to arbitrate disputes
I specifically agree that all claims against any of the Releases that I may have or choose to make shall only be submitted to binding arbitration under the rules of the Arbitration Act or similar statute of my province of residence, and I waive any rights to pursue any claims or causes of action in any court of law.
