Creative Wellness Chiropractic
Patient Consent

Patient Consent

Consent Form

Consent to be treated for chiropractic

MM slash DD slash YYYY

Admission Consent (Privacy Practices)

I have received a copy of privacy practices. Dr. Sera Tekin’s office has my permission to leave phone messages at the phone number(s) I have provided. I also hearby authorize the release of any of my records pertinent to my care with any insurance company, adjuster or attorney involved in this case.

Admission Consent (Insurance Payment/Payment of Services)

Insurance Payment/Payment of Services. I hereby instruct and direct my insurance company to pay by check or EFT directly to Dr. Ser Tekin, 4849 Ronson Court, Suite 100, San Diego, CA, 92111 OR if my policy prohibits direct payment to the doctor, I am obligated to pay for services I have received at a reasonable rate.

Admission Consent (Consent to Treat)

I understand that, as with any health or medical procedure, there is some relative risk. If any type of treatment we offer in this office is contraindicated, Dr. Sera Tekin will discuss the details with me upon examination. I hereby request and consent to the care plan as outlined for me by Dr. Sera Tekin.

Admission Consent (Massage Cancellation Policy)

Our office is committed to providing all our patients with exceptional care. When a patient cancels or misses a massage without giving proper notice, they prevent another patient from being seen. Our mission is to try to help as many people as possible achieve their health goals. I understand that Dr. Tekin’s office requires at least 24 hours’ notice prior to any massage appointment cancellation. If i cancel my massage with less than 24 hours’ notice, I agree to pay a $25 missed appointment fee. I understand that if I do not show up to my appointment I will be subject to be charged the full cash value of my massage. **If a Monday appointment must be cancelled, we must receive cancellation by 12pm on Saturday.
MM slash DD slash YYYY