| Informed Consent for Treatment With Osteopathic Manual Medicine
Printable Version Thank you for selecting our office for evaluation and osteopathic treatment. We look forward to serving you. D.O.'s AND OSTEOPATHIC MANUAL MEDICINE An osteopathic physician is a fully licensed physician, (i.e. licensed to prescribe medication and perform surgery), whose education combines the traditional methods of diagnosis and treatment with osteopathic manual medicine (manipulation). Osteopathic philosophy stresses holistic and preventive care. Osteopathic manual medicine is a form of treatment based on the concept that the structure of the human body influences the function. The goal of treatment is to improve the body's structure, in turn, enabling the body to function at a higher level of health. Treatment usually reduces the amount of pain experienced by the patient as well as increases the ability of the body to fight disease (i.e. stimulates the immune system). As in most forms of medical treatment, no specific results can be guaranteed. TREATMENT PROGRAM: OSTEOPATHIC MANUAL MEDICINE The physician will ask questions and perform a physical examination. The physical examination includes evaluation of the musculoskeletal system in order to detect any somatic dysfunction (abnormalities such as tenderness, asymmetry, restricted range of motion and abnormal changes in the muscles, joints, bones, connective tissue, etc.). The physician's goal is to locate then reduce or resolve this somatic dysfunction. Techniques range from a very light touch to more increased pressure. Other recommendations may be given to help the dysfunction, such as diet, exercise, or stretching regimens. TREATMENT PROGRAM: ACUPUNCTURE Along with Osteopathic Treatment, Medical Acupuncture is often employed in our office as a complementary treatment. Please go to www.acupunctureprofessor.com and take the quiz under the link ?Learn More About You? and bring the results in to Dr. Freckleton. Make sure to drink plenty of water before and after your acupuncture treatment. Also, it is important to note that in the 24 hours following acupuncture treatment the following should be avoided: Ice, Ice Cream, Alcohol, Sex, and Vigorous Activity. TREATMENT RISKS Patients rarely experience side effects, as osteopathic manual medicine is considered one of the safest and most non-invasive forms of medical treatment. Most side effects occur from chiropractic or other forceful types of manipulation. Chiropractic manipulation is not utilized; there are no treatments with quick forceful movements generated by the physician. However, for purposes of disclosure, the following side effects have been reported form all forms of manual medicine: Worse pain after treatment, numbness or weakness, fractures (broken bones), spread of pre-existing conditions such as undetected cancer, breaking loose of blood clots, stroke and tears in blood vessels. Although the above-listed complications are rare, patients should be made aware of the complications, some of which are serious in nature. Utilizing gentle techniques further reduces the occurrences of these rare complications. In more common cases, patients may experience mild muscle soreness, fatigue, or tenderness, similar to excessive sports activities or flu-like symptoms. This vital reaction to treatment usually resolves within a few days. APPOINTMENT Your appointment is time set aside for you and your physician. Without a 48-hour notice, patients who forget their appointment or cancel at the last minute will be charged. Please understand we allow a significant amount of time for each patient visit and a missed appointment is lost time, which could have gone to a patient on the waiting list. Our office will endeavor to contact patients one working day in advance to confirm your appointment; however, the appointment is the patient's responsibility. Initial evaluation and treatment last approximately 90 to120 minutes. Follow-up treatments usually last 30 to 40 minutes. POSITIVE ACCOUNT BALANCE & RETURNED BANK ITEMS To cover our administrative cost, we will add a late charge of a minimum of $10 or 1.5% (whichever is greater) on all accounts not paid in full each month. If your check is returned from the bank, we will add a "returned check" fee to your account, usually in the amount of $25. There are no refunds. However, the doctors may choose to refund any portion of payment. PAYMENT Your insurance company may not reimburse for part or all of the Physician's services. Please note that payment is required at time of visit and that you or your legal guardians are personally responsible for an unpaid balance. We will provide you with a "Super bill" (a form detailing medical treatment, diagnoses, and charges) for each visit, which can be submitted to your insurance company. We regret that we are unable to accept the following: (1) Disability Insurance (2) Worker's Compensation (3) Medicaid (4) Medicare (5) Liens (6) Assignment from your Insurance Carrier Thank you for taking the time to read this agreement. We understand that you have come here to seek specialized treatment and we will endeavor to assist you in a speedy recovery. If you have any concerns or specific questions regarding the risks or benefits of treatment, please ask the physician before signing the consent form. CONSENT FOR TREATMENT I understand and agree to the above and agree to be treated. If the patient is a minor, I give my consent to have them treated. Patient name (print):______________________________________ Signature of patient or legal guardian:_______________________ Date:___________________ |
