• PRACTICE RULES

    1. Be as forthcoming and upfront as you can regarding your medical history & current condition. It really helps us give you better care.
    2. Stay current with your co-pays and financial arrangements with the office. If you run into trouble, talk to us sooner, rather than later. We will do what we can to help you get the care you need.
    3. Chiropractic care works best when you follow a schedule of care with visits planned out ahead of time. Better to have an appointment and change it, than to have no appointment at all.
    4. Call us if you are running late or need to reschedule an appointment. That frees up a time for another patient and helps us stay on-time.
    5. If you are unhappy with us- Let us know. We can’t see our blind spots. If you are happy with us-Let others know. Write an on-line review or refer a family member or friend.

  • USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI).

  • You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice may be found in the magazine rack in the reception area. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
    You may obtain a copy of our Notice of Privacy Practices including any revisions of our Notice, at any time by contacting: Contact Person: Schantz Chiropractic P.C. Office Manager Telephone: 770-993-9287 Fax: 770-993-1203 E-mail: office.schantz@earthlink.net Address: 600 Houze Way Suite A1 Roswell, GA 30076. Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

  • CONSENT FOR TREATMENT OF MINOR CHILD

  • Consent is hereby given by the undersigned for chiropractic treatment and diagnostic studies as ordered by the doctors and performed by the technical staff of Schantz Chiropractic, P.C. The undersigned states that he/she is the patient's legal guardian.

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