Consent for Treatment

Consent for Treatment & COVID-19 Waiver of Responsibility

Chiropractic Consent

Chiropractic examination and therapeutic procedures (including spinal adjustment, ultrasound, heat application, electrotherapy, hot laser therapy and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. These complications include but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns and temporary worsening of symptoms. 

Acupuncture Consent

I understand that acupuncture is performed by the insertion of needles through the skin at certain points on the body to treat bodily dysfunctions or diseases, to modify or prevent pain, and to make normal the body's physiological functions. The procedure has been fully explained to me. I have been made aware that certain adverse side effects may result. These include, but are not limited to: some local bruising, minor bleeding, fainting, temporary pain or discomfort, and possible temporary aggravation of symptoms existing prior to acupuncture treatment. I understand that the acupuncturist may recommend substances from the Oriental material medica to treat bodily dysfunctions or diseases, to modify or to prevent the perception of pain, and to normalize the body's physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I decide to take them.

I have been made aware that certain adverse side effects may result from taking these substances. These could include, but are not limited to, changes in bowel movement, temporary abdominal pain or discomfort, and the possible temporary aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and contact my acupuncturist.

Massage Consent

I understand that the massage I receive is for the purpose of stress reduction and relief of muscular tension, spasm, or pain, and to increase circulation. If I experience any pain or discomfort, I will immediately inform the therapist so that the pressure or methods used can be adjusted to my comfort level. I understand that massage therapists do not diagnose illness or disease, nor do they perform spinal manipulations or prescribe any medical treatments, and nothing said or done during the session should be construed as such. I acknowledge that massage is not a substitute for medical examination or diagnosis, and I should see a health care provider for those services. Because massage should not be performed under some circumstances, I agree to keep the massage therapist updated as to any changes in my health, and I release the massage therapist and Holistic Health Clinic from any liability if I fail to do so.

Naturopathic Consent

I, the undersigned, hereby authorize Dr. Michelle Young to perform the following procedures necessary to facilitate my treatment. Medical treatments and procedures not within the scope of her licensed practice will be referred to an appropriate provider.

  • Botanical Medicine and Nutritional Supplementation: herbal formulations, vitamins, minerals, amino acids recommended in therapeutic and/or maintenance doses.
  • Bio-identical hormone replacement therapy: clinical and laboratory evaluation and appropriate prescriptions from a compounded pharmacy.
  • Acupuncture: insertion of specialized sterile needles through the skin into the underlying tissues at specific points on the body.
  • Cupping: a technique to release myofascial tension by applying glass cups to the skin, using heat to create a vacuum seal.
  • Moxa: an indirect warming technique along acupuncture meridian
  • Naturopathic Manipulation Therapy, including Bilateral Nasal Specific: adjustment of soft tissue and joints to optimize range of motion, reduce nerve impingement and promote blood flow
  • Injection therapies: a combination of dextrose, lidocaine and/or procaine is injected into muscles, tendons and/or joints to release trigger points, promote the regeneration of tissues, improve mobility and alleviate pain.

Potential Risks: unsuspected reaction at the site of injection/acupuncture, an aggravation of symptoms existing prior to treatment, allergic reactions to recommended treatments, side effects of natural medications, injury from needle insertion, injections, or venipuncture.

Notice to Pregnant Women: All female patients must alert the doctor immediately if they know or suspect that they are pregnant, as some of the therapies used could present a risk to the pregnancy.

With this knowledge, I voluntarily consent to the above procedures, realizing that Dr. Michelle Young has given me no guarantees regarding cure or improvement of my condition. I hereby release Holistic Health Clinic from any and all liability, which may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. I acknowledge that Holistic Health Clinic is not responsible for patient compliance and will not be held responsible for outcomes due to patient non-compliance. I understand that I am free to withdraw my consent and to discontinue participation in the above procedures at any time.

By signing I agree that I have read and understand the above and consent to treatment.

COVID-19 Assumption of Risk and Wavier

Tabor Sun Chiropractic dba Holistic Health Clinic (HHC) has put in place the following preventative measures to reduce the spread of COVID-19: implemented physical distancing within our clinic setting, including floor markers for traffic control, sanitization of all contact surfaces in our office, treatment rooms and commonly used utensils, practice thorough hand washing, obtained a temperature reading of each patient up on arrival and implemented a screening questionnaire.

As a patient, we ask that you do your part to reduce the spread of COVID-19 by: staying home if you are sick, informing us if you have been ill in the past or have been exposed to someone with known or presumptive Sars.CoV2, wear a mask when you are in our office and treatment rooms, wash your hands before and after your appointment, wait curbside and call the clinic before entry, submit to a temperature reading before you enter the building and follow guidelines regarding traffic flow once inside the building.

By signing this document, you agree that you fully understand that this risk of becoming exposed to or infected by Sars.CoV2 may result from the actions, omission, or negligence of yourself and others, including but not limited to, Holistic Health Clinic staff, other patients and their family members. We cannot guarantee that you or anyone accompanying you will not become infected with Sars.CoV2 when attending our facility for treatments; however, if you are concerned about your risks please consult your medical provider.

We appreciate your continued patronage to the Holistic Health Clinic and your honest effort in joining us to help reduce the spread of the coronavirus.

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

Office Hours

Monday

10:00 am - 7:00 pm

Tuesday

10:00 am - 7:00 pm

Wednesday

10:00 am - 7:00 pm

Thursday

10:00 am - 7:00 pm

Friday

10:00 am - 7:00 pm

Saturday

10:00 am - 5:00 pm

Sunday

10:00 am - 5:00 pm

Monday
10:00 am - 7:00 pm
Tuesday
10:00 am - 7:00 pm
Wednesday
10:00 am - 7:00 pm
Thursday
10:00 am - 7:00 pm
Friday
10:00 am - 7:00 pm
Saturday
10:00 am - 5:00 pm
Sunday
10:00 am - 5:00 pm

Location

New Patient Inquiry