What to Expect On Your First Visit

New Patient Forms

After you make your appointment, our online intake registration forms are at the bottom of this page. It is important that you complete them fully prior to your appointment. Upon entering our office, we will confirm your registration is complete. The intake registration provides the doctor with important information about yourself and your condition. Bring your identification card and a health insurance card if you would like insurance claims submitted. (Please click on the links below to complete the New Patient Registration prior to your first visit.)

Paperwork can be completed on a computer, tablet, or phone.

PATIENT DEMOGRAPHICS


Have you served (past or present) in the active military, naval, or air service? If so, you may be eligible for VA health care benefits.*
Please select at least one option
Have you been in a Motor Vehicle Accident in the past 30 days?*
Please select at least one option
HOW DID YOU HEAR ABOUT US?*
Please select at least one option

Assignment and Release

I certify that I have read and understand the above information. The above questions have been accuratelyanswered. I authorize the chiropractor to release any information including the diagnosis and the records ofany treatment or examination rendered to me or my child during the period of such chiropractic care to thirdparty payers and/or health practitioners. I authorize and request my insurance company to pay directly to Palmercare Chiropractic LLC, any insurance benefits otherwise payable to me. I understand that I am responsiblefor all charges. If the doctors are participating providers for my insurance, I understand that I am responsiblefor any co-payments, deductibles, or other charges in accordance with my plan. I also understand that shouldmy account be placed with an agency or attorney for collection, then I agree to be responsible for all costsincurred in the collection of my account, including attorney's fees, interest at 1.5% per month (18% annual),and all court costs. The laws of the Commonwealth of Virginia Govern this agreement. If litigation arises out ofthis agreement, venue shale be in the Courts of Loudoun County, Virginia.

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

In the course of your care as a patient at Palmercare Chiropractic LLC we may use or disclose personal and health related Information about you in the following ways:

*Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.

*your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of services provided to you.

*Your name, address, telephone number, e-mail address and health records maybe used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you.

You have the right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.

If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have aright to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted be alternative means or at alternative locations.

We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:

*If we provide health care services to you in an emergency.

*If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.

*If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

*If we are ordered by the courts or another appropriate agency.

You have a right to receive an accounting of any such disclosures made by this office.

Any use or disclosure of your projected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a specific form please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing.

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are furthered required by law to abide by the terms of this notice while it is in effect.

We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: One of the doctors of the office.

If you would like further information about our privacy policies and practices please contact: One of the doctors of the office.

You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective as of June 27,2005. This notice, and any alterations or amendments made here to will expire seven years after the date of the record was created. My signature acknowledges that I have received a copy of this notice.

INFORMED CONSENT TO TREATMENT

The primary treatment used by doctors of chiropractic is spinal manipulations or adjustments. We will use this procedure in your treatment program.

The nature of Chiropractic manipulation/adjustment: We will use our hands to manipulate or loosen and reposition the joints of your spine. Often with this procedure, you will hear a popping noise associated with the loosening and repositioning. We may also use a mechanical adjusting instrument, called an Activator.

The material risks inherent to Chiropractic manipulation/adjustment: As with any health care procedure, there are certain complications that may arise from chiropractic manipulation. These complications may include aggravation of degenerative or injured spinal discs, rib fractures, ligament sprains, muscle strains, nerve injury or spinal cord compression. Manipulation of the neck has been associated with injury to arteries in the neck leading to or contributing to stroke. Local soreness and/or stiffness is typical in the early phases of treatment.

Probability of those risks occurring: Fractures are rare occurrences and generally result from underlying bone weakness which we check for during your history, examination and x-rays. The exact incidence of stroke is uncertain, but it is generally believed to occur in less than one per million treatments. We employ physical tests that are advocated to screen for this risk, but they are generally accepted as being insensitive. All other complications are also generally described as rare.

The availability and nature of other treatment options: Other treatment options for your condition may include:

-over the counter medications and rest

-Medical care which may include anti-inflammatory drugs, muscle relaxants, and pain medications

-Surgery

Material risks inherent to your other treatment options: The common analgesics and anti-inflammatory drugs have been shown to cause damage to the stomach and intestines, and possibility to the kidneys. Approximately 1 in 150 patients taking anti-inflammatory drugs for extended time periods require hospitalization for stomach ulceration. There are about 16,500 deaths in the U.S. each year from these complications, which is more common than deaths from either Hodgkin's disease or cervical cancer. The risks are similar for both prescription anti-inflammatories as well as over-the-counter medications.

Spine surgery may be a consideration for some cases. It, however, is reserved for those cases where extensive conservative treatment has been tried. Spinal surgery is associated with a minor complication rate of between 9 per 100 and 15 per 100 cases depending on the area of the spine involved. More serious complications of the nervous system may occur in 1 per 400 cases, and death has been reported in approximately 1 per 1500 cases.

While spinal manipulation is associated with complications in a smaller number of cases, it has a complication rate of several thousand times less than other typical treatment options.

Laser Treatments:

There are potential risks and complications associated with all laser procedures. Although the majority of patients donot experience these complications, you should discuss each of them with your doctor or laser operator to make sureyou understand the risks, potential complications, and consequences of laser treatments.

Laser energy can produce burns. Appropriate eye protection must be worn during the entire procedure to avoid damage to the eyes. Adjacent structures, including the eyes, may be injured or permanently damaged by the laser beam without proper gear. Burns are rare yet can occur and may require additional procedures to treat.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

I have read or had read to me the above explanation of chiropractic manipulation or adjustments and related treatment. I have discussed it with the doctor and have had my questions answered to my satisfaction. 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 treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

Thank you for taking the time to fill out this form.

*Each section must be completed in its entirety. Please be detailed, listing all complaints for the doctor to best understand your condition and health history.

*Be sure to sign your name electronically at the bottom of the form, use your mouse, when completed choose "submit form".

Consultation & Case History

Once you have completed the registration process, you will have a consultation with the doctor. During this time you will  discuss your case history and any health-related problems. The doctor will ask you various questions to get a clear understanding of your condition.

Examination

In order to determine what your actual problem is, the doctor will perform chiropractic, orthopedic, and neurological tests. The focused physical examination will be performed to determine the cause of discomfort, and the extent of injury.

X-Ray Studies

X-Rays will be taken if the doctor feels it is necessary for your diagnosis.  If performed, they are taken to properly determine your condition and to rule out any other serious health problems or contraindications to treatment.

Report of Findings

The doctor will discuss your case findings and a plan of treatment. You are encouraged to ask any questions regarding your condition and prognosis to get a clear understanding of how you can benefit from chiropractic care.

Treatment

After the Report of Findings, your treatment may include spinal manipulation, therapeutic modalities, or decompression therapy. Each patient's condition is unique to him or her and all treatments are tailored to your individual needs and how you respond.

Home Instructions

Depending on your condition, you may be given instructions on certain activities or procedures to be conducted at home. This may include ice or heat application instructions, and avoidance of certain activities or positions.

Payment for Services

After services have been provided, you are responsible for payment. We accept cash, personal check, VISA, and MasterCard. If you have health insurance you will be responsible for any deductible or copayment amounts due. Our insurance department will bill your primary health insurer if you desire.

Schedule Your Next Appointment

Our front desk staff will assist you with finding a convenient appointment time for your follow-up visit. You will be encouraged to maintain your care recommendations to experience the best and most immediate health benefit.

Insurance Provider List

Note that these are the primary insurance providers we service, we participate with others as well. We accept most all PPO plans. Please contact our office to ensure that we  participate with your insurance provider.

The Veterans Administration (VA) covers chiropractic benefits at 100% for service related injuries with a referral from your VA Physician.

We look forward to working with you to achieve better health!