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Schaffstall Chiropractic, LLC
Call for Consulation 716.580.3246

First Visit

What to know about your first visit

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Welcome to Schaffstall Chiropractic!

On your first visit, you can look forward to a pleasant and serene surrounding to experience the most complete Chiropractic care in the Buffalo region.  Upon arrival, you will be warmly greeted and provided paperwork which you will need to complete.  To save time, you may download the intake forms and complete the paperwork ahead of time and bring with you to your appointment.  Please use the links at the top of the page (if you wish to) to download the forms.

 

During your visit, you will be given a tour of the office and opportunity to have any questions you may have about Chiropractic answered. 

A complete and thorough examination will be performed.  If appropriate, a treatment will be given during your first visit.

X-rays may be required for certain but not all conditions.

Please take a moment to review the following form below.  Before your treatment begins, you will be asked to sign a copy of this.  This form will be provided for you at your first visit.

 

Please arrive 15 minutes early to fill out paperwork if you do not do so ahead of time.






NOTICE OF CLIENT PRIVACY RIGHTS

By signing below, I acknowledge that I have received a copy of the “Notice of Client Privacy Rights” and a copy will be available for me at the reception desk upon my request.  The Health Insurance Portability and Accountability Act (HIPAA) ensures a client’s right to privacy regarding personal health information and it is this office’s policy to maintain confidentiality to the highest degree.

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Client/Legal Guardian Signature                          Date

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Doctor’s Signature                                                  Date

 

OFFICE POLICIES

I agree to take full financial responsibility for my care in the event that the assumed coverage (Worker’s Compensation, No Fault Insurance, etc) is denied for any reason. I further understand that the office charges a $20 fee for returned checks.  I also understand that this office operates on a fee-for-service basis to be collected upon arrival for appointment.

The office reserves the right to charge for appointments cancelled without 24 hours notice and for not attending scheduled appointments.  The office will charge up to 100% of the cash value of the scheduled appointment.  Clients late for appointments have the option of either using the remainder of the time scheduled at the full price as scheduled, or the client may reschedule the appointment and be charged for the missed visit.


The office asks for your email address for appointment reminders and to communicate office announcements, changes and updates.

_________________________________                 _________________
Client/Legal Guardian Signature                          Date

_________________________________                 _________________
Doctor’s Signature                                                  Date

 

CONSENT TO TREATMENT

I hereby request and consent to the performance of chiropractic evaluation/care, manipulations, and/or any other chiropractic procedures by any licensed provider of Schaffstall Chiropractic, any future provider of Schaffstall Chiropractic, or any relief provider for my regular provider.

While Chiropractic examination and therapeutic procedures are usually considered to be remarkably safe and effective, occasionally there may be adverse reactions.  Although the chances of experiencing any of these complications are extremely small, it is the practice of this office to fully inform and educate all of our clients.  By signing below, I understand that these complications include, but are not limited to, allergic reactions, muscle soreness or bruising, muscle strain, sprains, fractures, dislocations, disc injuries, and strokes.  I do not expect the provider to be able to anticipate or explain all possible risks and complications.  I wish to rely on the provider to exercise judgment during the course of my treatments which they feel at the time, based upon the facts then known, is in my best interests.  I intend this consent form to cover the entire course of treatment for present condition and future condition(s) that I may seek treatment for.

I understand that there is not guarantee or warranty for a specific cure or result.  I understand that at any time, I can request further explanation regarding risks and benefits of care in this office, alternative courses of care, and the consequences of not having the proposed treatment.  Further, I agree to notify the provider immediately with any concerns, if I were ever to become uncomfortable for any reason – treatment is too much to tolerate, personal issues with space or touch, religious, etc.

_________________________________                 _________________
Client/Legal Guardian Signature                          Date

_________________________________                 _________________
Doctor’s Signature                                                  Date


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