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I am interested in receiving FIH services:
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Do you have any notable conditions that should be considered during care with Flourish practitioners?
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Services of Interest:

INSURANCE INFORMATION:       

 

If you are hoping to use insurance to cover chiropractic care, we are happy to verify your insurance coverage.  We will NEVER bill your insurance without your permission.  It means we will verify your benefits and have that information prepared for you by your second visit. 

 

Who is responsible for this account? ____________________

 

Relationship to client: ____________________________

**Please upload a photo of the front AND back of your current insurance card below**.

The following are important for my self-care
Front of card
Max File Size 15MB
Back of card
Max File Size 15MB
Please upload your
current Identification Card
Front of ID
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Back of ID
Max File Size 15MB

If interested in yoga, what kind of yoga have you practiced? How often?

Please read this entire agreement prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. Using  services and programs of Flourish Intuitive Health (FIH) for any purpose, including, but not limited to Massage, Yoga, Chiropractic Care, Acupuncture, Nutrition Wellness or participation in any off-site program affiliated with FIH, the undersigned for herself or for such participation of their spouse and children agrees :

1. CONSENT TO TREATMENT: One of the treatments that may be employed under chiropractic care is spinal and or extremity manipulative therapy. The undersigned requests and consents for Dr. Mark Chappell-Lakin, D.C.  to perform evaluation and treatment for all chiropractic related conditions, whether pre-existing or current. 

 

2. RISKS: As with many Wellness procedures, there are certain complications, which may arise during chiropractic manipulation and therapy. The client understands their responsibility to discuss these risks PRIOR to treatment. Some clients will feel some stiffness and soreness following the first few days of treatment. Dr, Mark will make every reasonable effort during the examination to screen for contraindications of care: however if you have a condition that would otherwise not come to the Doctor’s attention it is your responsibility to inform the Doctor.

 

3. I understand that any massage received from FIH staff, is for the purpose of stress reduction, pain reduction, relief from muscles tension, increasing circulation, or specific reasons you have stated under “additional comments” on this intake form.

I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.

 

I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.

 

I have listed all of my known physical conditions and medications, and I will keep my FIH practitioners updated on any changes. 

4. I understand and give consent to acupuncture treatment  and other complementary medicine procedures including various modes of therapy. 

I understand that methods or treatment may include,  but are not limited to :

acupuncture, moxibustion, cupping, moving cupping, electrical stimulation, Tui-Na (chinese massage), Chinese or Western herbal medicine, supplement recommendation and nutritional counseling.  

I understand that I am responsible to ask my FIH Practitioner any questions I may have before treatment and have all risks and complications explained.  I wish to rely on the FIH practitioner to exercise judgment during the course of the procedure, which the practitioner feels at the time, based upon the facts then known, is in my best interests.

 

 

 

5. I understand that the administrative staff may review my medical records and reports, but that all my records will be kept confidential and will not be released without my consent.  I have read or have had read to me, the above consent.  I have also had an opportunity to call and ask questions about this content. 

 

I understand that my client records and  information will be kept confidential and shared only when necessary to provide joint care services within FIH, or when required or permitted by law.

 

By signing below, I agree to the above-named procedures.  I intend this consent form to cover the entire course of treatment(s) for my present condition and for any future conditions(s) for which I seek treatment. 

(734) 489-1539