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  • Pediatric Health History

  • TERMS OF ACCEPTANCE

    CHIROPRACTIC HAS ONLY ONE GOAL AND THAT IS TO REMOVE NERVE INTERFERENCE CAUSED BY A MISALIGNMENT OF SPINAL BONES. IT IS IMPORTNAT THAT YOU UNDERSTAND THAT DIAGNOSING CONDITIONS, TREATMENT OF CONDITIONS, AND REMOVING PAIN IS NOT THE GOAL OF THIS OFFICE. LOCATING, ASSESSING, AND CORRECTING VERTEBRAL SUBLUXATION IS THE ONLY GOAL OF THIS OFFICE. ALTHOUGH THIS OFFICE MAY RELIEVE YOU OF SOME PAIN, MAINTAINING YOUR HEALTH AND FAMILY'S HEALTH THROUGH REGULAR SPINAL CHECKUPS AND SPINAL ADJUSTMENTS IS OUR PRIMARY GOAL. 

     

    "I understand that I will pay a total value of $100 (individual) or $150 (family of 2 or more members) for the initial visit. The initial visit consists of history taking, neurological chiropractic examination, reading of the radiology films, determing a uniquely designed care plan, goal setting, and the report of finding(s)."

  • Cancellation Policy:

    A $25 charge will be applied the day of the appoinment if you are more than 10 minutes late, and/or cancel/reschedule less than 24 hours prior to the appointment. 

    "I therefore accept chiropractic care on this basis"

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  • Pregnancy Health History



  • INFORMED CONSENT FOR CHIROPRACTIC CARE

    CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE

    INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

    PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.


    I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT. 

     


    I AUTHORIZE DR. SHIQUITA WHITE AND ANY AND ALL GOD FAMILY  CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.


    AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY GOD FAMILY CHIROPRACTIC.

    Print child/minor's name and sign.  

     

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