Minor Consent Form

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 Minor Consent for Treatment

Chiropractic Consent

Chiropractic examination and therapeutic procedures (including spinal adjustment, ultrasound, heat application, electrotherapy 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. More serious complications are extremely rare.

Additional information on side-effects and complications is available upon request.

I have read and understand the above statements regarding treatment side-effects. I also understand that there is no guarantee or warranty for a specific cure or result.

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.


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.

I have carefully read and understand all the above and am fully aware of what I am signing.

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.


Parental Acknowledgement

All persons under the age of 18 are required to have a parent or guardian fill out this form.

By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility for the entirety of the minor's treatment(s). You will also be required, if needed to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the practitioner and the minor.

You also agree that you have completed the Intake Form and have informed the practitioner of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).


I certify that I am the parent or legal guardian of the patient who is younger than 18 years of age as of today. I have completed the Intake Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of treatment he/she will receive at the Holistic Health Clinic and I give my full permission for my minor child to receive treatment at this facility and agree to all the above terms.

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

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

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

--mi

Holistic Health Clinic

Address

4670 SW Washington Ave
Beaverton, OR 97005

Contact Information (503) 646-8575

(503) 526-0783

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