1. The purpose of chiropractic care is to optimize health by facilitating neurological and biomechanical integrity, which allows maximum expression of the body’s innate recuperative abilities.

 2. you understand that chiropractic services will be provided by licensed Doctor of Chiropractic who are employed by Go Well GVL.

3. Go Well GVL uses only chiropractic methods that are taught in accredited chiropractic colleges, and appropriate techniques will be selected for my care based upon standard professional protocols. Your diagnosis and all proposed procedures will be explained to you and implemented only with your approval. Alternatives and adjunctive recommendations for health promotion will be discussed with you.

4. Chiropractic adjustments are exceedingly safe when applied properly. However, you understand there are some risks to take care for including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. You do not expect the doctor to anticipate and explain every risk and complication, but you will rely on the doctor’s best judgment to protect your best interests. No guarantees of cure have been implied or given.

 5. A small force is introduced into the spine during a chiropractic adjustment that may lead to temporary musculoskeletal discomfort. This is usually minor and transient.

 6. The doctor will discuss any further risks inherent in your particular case during a report of findings and will document this discussion in your case record. Any questions or concerns that you may have will be addressed at this time. You understand that you are an active participant in your chiropractic care, and that you are encouraged to bring up questions or express any concerns.

7. You give my permission for your doctor to communicate by telephone or email/text regarding matters of chiropractic care, appointment reminders or scheduling.

8. Go Well GVL is compliant with all HIPAA regulations and takes all reasonable precautions to safeguard your privacy in all matters. You understand that any concern you have regarding privacy and safety of your health information may be discussed with your intern or case doctor.

9. You are free to refuse care or withdraw your consent and discontinue care at any time.

 10. You affirm that you have read, or have read to you, this consent document, and you agree to its provisions. You intend this document to cover the entire course of care now and in the future.

 you understand that under the Health Insurance Portability and Accountability Act (HIPAA), you have certain rights to privacy regarding your protected health information (PHI). You acknowledge that you have received or have been given the opportunity to receive a copy of the Notice of Privacy Practices. You also understand that Go Well GVL has the right to change its Notice of Privacy Practices and that you may contact the Clinic at any time to obtain a current copy of the Notice of Privacy Practices. You also understand that you may withdraw your consent in writing. You give the Case Doctor or other Go Well GVL employees permission to contact you in the following ways: EMAIL, PHONE, & TEXT.

We strive to provide exceptional care to all clients in a timely manner and have implemented a 24-hour cancellation policy for appointments. We kindly request that you provide at least 24 hours' notice if you need to cancel or reschedule your appointment, allowing us to offer the time slot to another client. Cancellations or rescheduling within 24 hours will incur a 50% cancellation fee, and a no-show without any notice will result in the full cost of the service being charged. Please be aware that if you arrive late, we reserve the right to adjust the duration of your service. If you are more than 15 minutes late and we are unable to accommodate the full service within the remaining time, the full amount will be charged. We appreciate your understanding and cooperation.

To avoid a misunderstanding, we wish our patients to know that all professional services are charged directly to the patients and that patients are personally responsible for payment of services. We will gladly prepare the forms to help you obtain your benefits from insurance companies. We do not render our services based on if insurance companies and workman’s compensation will pay our fees.