Intake Form

Denver Holistic Chiropractic

Dr. Robert Weissfeld
New Patient Intake Form
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Terms of Acceptance of Care and Consent for Treatment
In the course of care, it is essential for the practitioner and client to work towards the same objectives. Here is a brief explanation of the goals and methods of treatment that will be used, and the risks of treatment.

Health:

A state of optimal physical, mental, emotional, and social well-being, not just the absence of disease or infirmity.

Chiropractic Adjustment:

The chiropractic method of correction is by specific adjustments of the spine, extremities, and/or cranium. An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation, a misalignment or fixation of one or more of the vertebra in the spinal column (which causes alteration of nerve function and interference to the transmission of nerve impulses), which can impair the body’s ability of achieve maximum health potential. As in the practice of medicine and all health care, the practice of chiropractic carries some risks to treatment, including, but not limited to, fractures, disc injuries, and strokes (CVA), dislocations, and sprains. Chiropractic treatments rank among the safest and most effective form of health care, and chiropractors' malpractice insurance rates remain among the lowest in the health professions.

Functional holistic treatment:

Functional holistic treatment endeavors to correct those things that are actually found to be dysfunctional, not a disease label. As such, I do not offer treatment based on diagnosis or treat any specific disease or condition. (Disease is defined here as a collection of symptoms and other findings that are labeled with a name – arthritis or pneumonia for example.) If during the course of examination and treatment, I encounter findings that suggest a pathology or that I feel are beyond my area of expertise or that I cannot treat, I will advise you.

If you desire further advice, diagnosis, or treatment for those findings, I recommend that you seek the services of a healthcare provider who specializes in diagnosis and treatment based on the diagnosis.

The therapeutic objective is to eliminate chemical, structural, neurological, or other interference to the expression of the body’s innate healing ability. The elimination of interference leads to improved health. My methods are: adjusting to correct vertebral subluxations, specific muscle work, acupuncture or laser or electro-acupuncture, techniques to support self-awareness, and nutritional supplementation, all provided as needed.

Feel free to ask whatever questions you need to fulfill your understanding. You may at any time refuse or decline a specific treatment or test that you feel uncomfortable with.

Because the treatment provided relaxes compensations that may be keeping symptoms at bay, temporary aggravation of symptoms or new symptoms may be experienced. Should this occur, it is important that you call me if the symptoms feel intense or you are concerned.

I treat all patients equally, regardless of age, sex, race, nationality, or sexual orientation.

Payment

Unless previous arrangements are made, payment in full is due at the time of the visit, as check, cash, or Credit Card. Despite efforts to be assured of insurance coverage before treatment, at times the insurance will not cover some or all of the examinations and treatment. A promise of payment by your insurance does not eliminate your personal responsibility for payment. Missed appointments not canceled at least 24 hours prior to the visit will be charged full price.

Privacy Notice

This Practice is committed to maintaining the privacy of your protected health information. A Privacy Notice is posted atDenverHolisticChiropractic.com that provides a more complete description of information uses and disclosure. You have the right to review the notice prior to signing this consent.

Sincerely,

Robert Weissfeld D.C., C.N.T.
I understand that all questions regarding the doctor’s objectives pertaining to my care in this office will be answered to my satisfaction.

I do not expect that physicians to be able to anticipate and explain all risks and complications. I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests, at the time, based upon the facts then known. I, therefore, accept and authorize care on this basis.
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Denver Holistic Chiropractic

New Patient Intake Form

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Terms of Acceptance of Care and Consent for Treatment