Patient Forms

Welcome to our office!

About this Patient

About the Spouse 

Employer Information

Reason for this Visit

Place an X on the image below, where you feel pain, numbness or tingling:

Experience with Chiropractic 

Awareness of Chiropractic Principles 
Were you aware that...

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Habits & Conditions

FOR WOMEN ONLY:

Consent to X-ray

I hereby grant KURV O2 PLLC permission to perform an x-ray evaluation considered necessary or advisable in the course of examination and/or treatment. I understand that x-rays are being performed to locate vertebral subluxation, and not to diagnose or treat any other disease or condition.

Emergency Contact

My Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

ABOUT THE INSURED PERSON

Nutrition and self-care are just two of the components in obtaining optimal wellness. 

Please let us know what you are currently doing for your health.

Initial Consultation Form 

Missed Appointments 

We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

• Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
• With the exception of emergencies, it is vital that you keep all your appointments. Reminder texts are sent to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week. There may be a $29 late cancellation or no show fee applied for missed appointments.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Insurance:

We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Agreement:

My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

HIPAA Notice of Patient Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say "no" to your request, but we will tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say "no" if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
• We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you ask us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1. 
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington D.C. 20201, calling 1-877-696-6775, or visiting www.hhs gov/ocr/privacy/hipaa/complaints/ .
•  We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care.
• Share your information in a disaster relief situation.
• Contact you for fundraising efforts.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

•  Marketing purposes.
• Sale of your information.
• Most sharing of psychotherapy notes.

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we use or share your health information? We typically use or share your health information in the following ways.

Treat you:

• We can use your health information and share it with other professionals who are treating you.

Example: a Doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization:

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services. This may include chiropractic interns/chiropractic associate(s)

• Sign-in-sheets may be used to register for your appointment with your provider.
• Your name may be called upon when the provider is ready to see you.
• We do utilize open adjusting and therapy areas. Private rooms are available, just ask.

• We may share your health information with a third party "business associates" that for example perform billing and/or transcription services. Your health information with a business associate also contains terms that protect your private health information.
• We may use and disclose your protected health information for internal marketing such as your name and address may be used to send you a newsletter regarding our practice, services, or products that may be of benefit to you.

Bill for your services:

• We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

•  We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information to these purposes. For more information see: http:/AMww.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.ntml.

Help with public health and safety issues — We can share health information about you for certain situations such as:

• preventing disease
• helping with product recalls
• reporting adverse reactions to medications
• reporting suspect abuse, neglect, or domestic violence
• preventing or reducing a serious threat to anyone's health or safety

Do research:

• We can use or share your information for health research.

Comply with the law:

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with the federal law.

Address workers' compensation, law enforcement, and other government requests:

• We can share health information about you:
• For worker's compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share information about you:
• In response to a court or administrative order
• In response to a subpoena
• In response to a discovery request
• In response to other lawful process

APPOINTMENT REMINDER

• The Practice may, from time to time, contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

• The following appointment reminders are used by the Practice: a) a postcard mailed to you at the address provided by you, and b) telephoning your home and leaving a message on your answering machine or with the individual answering the phone; c) Text message

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information
• We must follow the duties and privacy practices described in this notice and give you a copy of it
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change our mind at any time/ Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understandina/consumers/noticepp.htmi.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, an on our website.

Contact Information:

Kyle Knapp. DC

Privacy Officer Name

972-488-4994

Phone Number

https:/kurvo2.com

Website

You may also contact any member of our staff.

This notice becomes effective and was published on 10/01/2022.

PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received the Notice of Privacy Practices from the office of KurvO2, PLLC 1880 N Stonebridge Dr. Suite 240, McKinney, TX 75071 and I have been provided an opportunity to review it.

Assignment of Benefits, Assignment of Cause on Action, Contractual Lien

The undersigned patient and/or responsible party, in addition to continuing personal responsibility, and in consideration of treatment rendered or to be rendered assigns to KurvO2, PLLC, the following rights, power, and authority: 

RELEASE OF INFORMATION: You are authorized to release information concerning my condition and treatment to my insurance company, attorney or insurance adjuster for purposes of processing my claim for benefits and payment of services rendered to me.

IRREVOCABLE ASSIGNMENTS OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court loss, or other legally compensable amounts owned by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to cooperate, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits upon request.

DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for treatment rendered by the physician facility named above, you are hereby tendered demand to pay in full the bill for services rendered by the physician/facility named above within 31/45 days following your receipt of such bill for services to the extent such bills are payable under the terms of the policy. This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing for attorney fees, 18% penalty, court cost, and interest from judgment, upon violation. I further instruct the responsible party to make all checks payable to KURVO2 PLLC and send any checks to 1880 N. Stonebridge Dr. STE 240, McKinney, TX 75071.

THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the liability carrier to cut a separate draft to pay in full all services rendered, payable directly to the physician/facility named above.

STATUTE OF LIMITATIONS: waive my rights to claim any statute of limitations regarding claims for services rendered or to be rendered by the physician/facility named above, in addition to a reasonable cost of collection, including attorney fees and court costs incurred.

LIMITED POWER OF ATTORNEY: I hereby grant to the physician/facility named above the power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company representing payment for treatment and healthcare rendered by the physician/facility named above. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my / our account or forwarded to my / our address upon request in writing to the physician/facility named above.

TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as recommended to me by my caring doctor at this clinic, he/she has full and complete right to terminate responsibility for my care and relinquish any disability granted me within a reasonable period of time. If during the course of my care, my insurance company requires me to take an examination from any other doctor, I will notify this physician/facility immediately. I understand that the failure to do so may jeopardize my case.

Informed Consent to Care

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major Gl events of the entire (upper and lower) Gl tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

1880 N Stonebridge dr. STE 240

McKinney, TX 75071

Spinal Decompression Informed Consent

The nature of the spinal decompression: You will be harnessed in with 2 separate harnesses and your spine will be gently lengthened in order to decompress herniated or bulging discs or re-hydrate degenerated discs.

The material risks inherent with spinal decompression: As with any healthcare procedure, there are certain complications that may arise during spinal decompression. This may include strains, muscle spasms, disc injuries, and worsening of your pain. This list is not all-inclusive.

The probability of those risks: The complications listed are considered rare. The most common risk is a dull, achy soreness similar to having just worked out for the first time in along time. This is usually due to the stretching of tight muscles that haven't been stretched in this way. This will typically go away within the first week or two of treatments. We will warm the tissues up before treatment and will decompress your spine more conservatively at first to prevent as much soreness as we can. It is recommended that you ice for 20 minutes up to 3 times daily for the first week to decrease pain and soreness.

Ancillary treatments recommended: Ice, Moist Heat Packs, Cold Laser Therapy Stretching/Strengthening Exercises, Massage Therapy, and Electrical muscle stimulation.

Risks involved with the recommended ancillary treatments:

Ice, Heat, and Electrical Muscle Stimulation (EMS) can cause burning. The EMS can cause skin irritation underneath the active pads. Stretching/Strengthening Exercises and Decompression Spinal Traction can cause temporary post-treatment soreness or reflex muscle spasms. This list is not all-inclusive.

Other treatment options for your condition include medical care with prescription drugs, self-management with over-the-counter medication, rest, and/or surgery. There are material risks inherent in each of these options including but not limited to: addiction to medication, side effects of medication, improper self-dosages, and surgical risks including complications from either the procedure or the anesthesia.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

I have read or have had read to me the above explanation of spinal decompression and the related treatment. I have discussed it with the doctor and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. I understand that there are no guarantees as to the success of my individual treatment and that individual treatments may vary from patient to patient. I also understand that the payment for the treatment is pro-rated.

Nutritional Informed Consent

According to the Federal Food, Drug, and Cosmetic act, as amended, Section 201 (g) (1), the term "DRUG" is defined to mean: "Articles intended for use in the Diagnosis, Cure. Mitigation, Treatment or Prevention of disease."

A vitamin is not a drug, neither is a Mineral. Trace Element, Amino Acid Herb, or Homeopathic Remedy.

Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone.

Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of the foods in the patient's diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body. Nutritional advice and nutritional intake may also enhance the stabilized of chiropractic  adjustments and treatments.

I have read and understand the above:

X-Ray Pregnant Consent Form

To the best of my knowledge I am not pregnant or believe there is any possibility that I may be pregnant. I further understand that if I have any doubts, x-rays should not and will not be performed.

*The exam your doctor has ordered uses Ionizing radiation which can have a severe health effect during pregnancy to an unborn baby. The possibility of severe health effects depends on the gestational age of the unborn baby at the time of exposure and the amount of radiation it is exposed to. Unborn babies are particularly sensitive to radiation during their early development, between weeks 2 and 15 of pregnancy. Such consequences can include stunted growth, deformities, abnormal brain function, or cancer that may develop sometime later in life. You should contact your doctor if you believe you may be pregnant to discuss possible side effects and the risks and benefits of the procedure. If you feel that you may be pregnant, please inform the doctor before your exam.

RELEASE

I hereby consent to the photographing, video recording, or x-rays of myself and/or the recording of my voice and the use of these photographs, videos and/or x-rays, singularly or in conjunction with other photographs and/or records for advertising, publicity, commercial or other business purposes. I understand that the term "photograph" as used herein encompasses both still photographs, video, and x-ray images.

I further consent to the reproduction and/or authorization by KurvO2, PLLC to reproduce and use said photographs, videos, x-ray images and recordings of my voice, in all domestic and foreign markets. Further, I understand that others, with or without the consent of KurvO2, may use and/or reproduce such photographs and recordings.

If Model is under 18:

I have read this release and approve of its terms.