Informed Consent Form About the research study: The use of the Webster Technique in pregnant patients within

a practice-based research network

With your permission, some information from your records may be used for research. This will include

information about your demographics (such as your age, gender and education level). We will also ask you

and your doctor to participate in surveys about your physical symptoms. Each questionnaire will take between 5 and 10 minutes of your time. There are 4 short surveys in all.

The information that we collect may help doctors understand more about the use of Webster’s technique in patients with low back pain.

All information about you will be kept completely confidential. No reference will ever be made in oral or written reports that could link you to the study. Only authorized persons will have access to your information.

We will never release any of the following information about you:

• your name, address, or telephone or fax numbers • specific dates related to you (for example: birth date, dates seen in the clinic)

• social security number, health plan numbers, our clinic’s record numbers, or any of your

account numbers .

Your participation in this study is voluntary. You may decline to participate. If you decide to participate, you

may withdraw from the study at any time.

NOTE: If you decline to participate or withdraw, it will not affect

your relationship with your doctor or your care in this office in any way.

Consent:

I have read and understand the above information. All questions I have about this information have been answered to my satisfaction. Having this knowledge, I knowingly agree to participate in this

study.

If you have questions at any time about this study, you may contact the researchers:

Dr. Joel Alcantara

Research Director- ICPA

327 N Middletown Rd

Media, PA USA 19063

research@icpa4kids.com

(610) 565-2360

If you have any questions about your rights as a participant in this research study, contact:

Dr. Brent Russell

Office of Sponsored Research and Scholarly Activity Life University

1269 Barclay Circle, Marietta, GA, 30060

brussell@life.edu

(770) 426-2641

Participant's name ________________________________________ (please print)

Signature _____________________________________________ date ________________

Patient Sociodemographic

Title: The use of the Webster Technique in pregnant patients within a practice-based research network

Attending Chiropractor Full Name: ________________

1. Patient Age: ___ years 2.Level of education achieved

 Some high school   High school graduate  Some college

 Associate's (2‐yr) Degree   4‐yr Baccalaureate       Masters  

   PhD or other Doctorate 

3. Parity (# of live births) for patient:______ 4. Weeks of Gestation for presenting pregnancy:_____ 5. Primary pregnancy provider:     OB/GYN      MD      Midwife      Nurse‐Midwife  

 Other (describe): _______________________

6. Does your primary-pregnancy provider know you are attending chiropractic care?  Yes      Yes and referred me to the DC

  No 

7. Fetal Position of current pregnancy:

 vertex       occipito‐posterior   occipito‐transverse    face    

   brow   breech      transverse lie     

   Other (describe): _________________________

8. How was the baby's position determined:

    Ultrasound Imaging    Palpation 

   Both Ultrasound and Palpation 

   Other (describe): ________________________

9. Please describe your pregnancy-related musculoskeletal complaint(s):  Neck Pain     Mid‐back pain   Low back pain

   lower extremity/leg pain: ________________________

 upper extremity (arm/hand pain)  

   Shoulder pain 

 

10. Have you received care elsewhere (medical or alternative therapy) for your pregnancy-related musculoskeletal complaint.   Yes      No  

11. If you received care elsewhere or had self care, please answer all that applies to

your situation

Self care with over-the-counter medications

Self care with herbal products

Self care with nutritional products

     Self‐care with exercise

  Medical Care (please describe): _________________ 

     Chiropractic care elsewhere  

    Acupuncture

    Other (please describe): ___________________________________________________ 

 

12. Have you received instructions on any forms of exercises to perform during your pregnancy? Yes      No 

If YES please indicate the provider giving instructions/prescription:  MD        DC         Midwife         Self‐care or self‐taught

      Other (please describe): ______________________________________________ 13. What is your motivation for attending chiropractic care (please choose all that apply)  Wellness Care  

   To address musculoskeletal pain complaints 

   Other (describe): __________________________________________________________ 

14.What is your main source of information to help you decide to attend chiropractic care?    Previous or on‐going chiropractic patient  

   Internet 

   Friends and Family

   Referred by Medical Doctor  

   Referred by Midwife 

   Other (describe): ___________

PROMIS–29 Profile v1.0

Participant Format © 2009 PROMIS Health Organization and PROMIS Cooperative Group Page 1 of 2

Please respond to each question or statement by marking one box per row.

Physical Function Without

any difficulty

With a little

difficulty

With some

difficulty

With much

difficulty Unable to do

1 Are you able to do chores such as vacuuming or yard work? ...........................

2 Are you able to go up and down stairs at a

normal pace? ..............................................

3 Are you able to go for a walk of at least

15 minutes? ................................................

4 Are you able to run errands and shop? .......

Anxiety In the past  7  days… Never Rarely Sometimes Often Always

5 I felt fearful ................................................

6 I found it hard to focus on anything other than my anxiety ..........................................

7 My worries overwhelmed me .....................

8 I felt uneasy ................................................

Depression In the past 7 days... Never Rarely Sometimes Often Always

9 I felt worthless ............................................

10 I felt helpless ..............................................

11 I felt depressed ...........................................

12 I felt hopeless .............................................

Fatigue During the  past  7  days… Not at all A little bit Somewhat Quite a bit Very much

13 I feel fatigued .............................................

14 I have trouble starting things because I am tired......................................................

In  the  past  7  days… 15 How run-down did you feel on average? ...

In the past 7 days… Not at all A little bit Somewhat Quite a bit Very much 16 How fatigued were you on average? ..........

PROMIS–29 Profile v1.0

Participant Format © 2009 PROMIS Health Organization and PROMIS Cooperative Group Page 2 of 2

Sleep Disturbance In  the  past  7  days… Very poor Poor Fair Good Very good

17 My sleep quality was ..................................

In  the  past  7  days… Not at all A little bit Somewhat Quite a bit Very much 18 My sleep was refreshing.............................

19 I had a problem with my sleep ..................

20 I had difficulty falling asleep ....................

Satisfaction with Social Role In  the  past  7  days… Not at all A little bit Somewhat Quite a bit Very much

21 I am satisfied with how much work I can do (include work at home) .........................

22 I am satisfied with my ability to work

(include  work  at  home)………………

23

I am satisfied with my ability to do regular personal and household responsibilities ..........................................

24 I am satisfied with my ability to perform

my daily routines ........................................

Pain Interference In  the  past  7  days… Not at all A little bit Somewhat Quite a bit Very much

25 How much did pain interfere with your day to day activities? ..................................

26 How much did pain interfere with work

around the home? .......................................

27 How much did pain interfere with your

ability to participate in social activities?

28 How much did pain interfere with your

household chores? ..................................

Pain Intensity In  the  past  7  days…

29 How would you rate your pain on average? ..........................................

0

1

2

3

4

5

6

7

8

9 10

No

pain Worst imaginable pain

RAND Patient Satisfaction Survey

Title: The use of the Webster Technique in pregnant patients within a practice-based research network

Attending Chiropractor Full Name: ________________

Chiropractic Visit #: ____ Thinking about your visit with the physician/health care professional you have, how would you rate the following: Poor Fair Good Very Good Excellent 1. How long you waited to get an appointment O O O O O 2. Convenience of the location of the office O O O O O 3. Getting through to the office by phone O O O O O 4. Length of time waiting at the office O O O O O 5. Time spent with the physician/health care O O O O O professional you saw 6. Explanation of what was done for you O O O O O 7. Technical skills (thoroughness, carefulness, competence) of the physician/health care O O O O O professional you saw 8. The personal manner (courtesy, respect, sensitivity, friendliness) O O O O O of the person you saw 9. The visit overall O O O O O

 

Mama’s Chiropractic Clinic 3108 Del Prado Blvd S Unit 6 Cape Coral, FL 33904

Phone: (239) 549-6262 Fax: (239) 676-0111 www.mamaschiropractic.com

HEALTH CARE AUTHORIZATION FORM

I have been provided with a copy of the Notice of Privacy Practices for Protected Health Information. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (PHI) that will occur in my treatment, payment of my bills or in the performance of health care operations of this chiropractic office. A copy of our notice is attached and we encourage you to read it and request your own copy if you would like one. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information. I hereby give permission to Mama’s Chiropractic Clinic to use and/or disclose Protected Health Information in accordance with the following: SPECIFIC AUTHORIZATIONS: • I give permission to Mama’s Chiropractic Clinic to use my address, phone number and clinical

records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, information about treatment alternatives or other health related information.

• If Mama’s Chiropractic Clinic contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.

• I give permission to Mama’s Chiropractic Clinic to use my name on a welcome board, referral board, and birthday board.

• I give permission to Mama’s Chiropractic Clinic to use my photograph on their patient picture

bulletin board and other marketing materials such as their brochure, website, social media and ads in print media.

• I give permission to Mama’s Chiropractic Clinic to use any testimonial written by me for

marketing purposes such as, sharing with other patients or potential patients, in their brochure, on their website, social media or in ads in print media.

• I give Mama’s Chiropractic Clinic permission to treat me in an open room where other patients

are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with doctor at any time in private, the doctor will provide a room for these conversations.

• By signing this form you are giving Mama’s Chiropractic Clinic permission to use and disclose

your protected health information in accordance with the directives listed above. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. This authorization will remain in effect for the duration of my care at Mama’s Chiropractic Clinic plus 7 years or until revoked by me.

(over)

RIGHT TO REVOKE AUTHORIZATION: You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Mama’s Chiropractic Clinic. The written notice must contain the following information: Your name, Social Security number and date of birth;

A clear statement of your intent to revoke this AUTHORIZATION; The date of your request; and Your signature.

The revocation is not effective until it is received by the Privacy Official. This AUTHORIZATION is requested by Mama’s Chiropractic Clinic for its own use/disclosure of PHI. (Minimum necessary standards apply.) I have the right to refuse to sign this AUTHORIZATION. If I refuse to sign this AUTHORIZATION, Mama’s Chiropractic Clinic will not refuse to provide treatment however, it will not be possible for Mama’s Chiropractic Clinic to file third party billing on my behalf and I will be responsible for 1)payment in full at the time services are provided to me 2) scheduling my own appointments since Mama’s Chiropractic Clinic will be unable to contact me 3) all contact with Mama’s Chiropractic Clinic regarding my care. Additionally, any collection activity as permitted by law is not waived by refusal to sign the authorization. I have the right to inspect or copy, within boundaries, the protected health information to be used/disclosed. A reasonable fee for copying will apply. A copy of the signed authorization will be provided to me.

HEALTHCARE AUTHORIZATION I have read and understand this Healthcare Authorization Form and acknowledge receipt of The Notice of Privacy Practices for Protected Health Information. My signature below represents agreement with these practices. SSN: DOB: Patient’s name (please print): _______________________________________ Patient’s Signature: ________________________________________ Today’s Date: __________________________ Name of Personal Representative (if someone is designated to act on your behalf/or for a minor) Parent or Personal Representative name (please print): Signature: Description of Representative’s Authority to Act on Patient’s Behalf: ______________________________________________________________________________

Informed Consent We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent. Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health. Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation. A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, photographs, specialized instrumentation, radiological examination (x-rays), and laboratory testing. The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in the management protocol. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life. In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. Risks associated with physiotherapy may include the preceding as well as allergic reaction and muscle and/or joint pain. In addition there are

Mama’s Chiropractic Clinic 3108 Del Prado Blvd S Unit 6

Cape Coral, FL 33904 Phone: (239) 549-6262 Fax: (239) 676-0111

www.mamaschiropractic.com

reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment. I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment. I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE MAMA’S CHIROPRACTIC CLINIC AND ITS EMPLOYEES TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT. DATED THIS ____ DAY OF _____________, 20___ ______________________ ______________________ Patient Signature Doctor’s Signature Parental Consent for Minor Patient: Patient Name: ____________________________ Patient age: ___________ DOB: ____________ Printed name of person legally authorized to sign for Patient: ________________________________ Signature: ______________________________ Relationship to Patient: ____________________ In addition, by signing below, I give permission for the above named minor patient to be managed by the doctor even when I am not present to observe such care. Printed name of person legally authorized to sign for Patient: ________________________________ Signature: ______________________________ Relationship to Patient: ____________________ Remarks:

OFFICE EXPECTATIONS

In order to provide you with the best possible care for yourself and your family, we ask you to cooperate with us in several different areas. Therefore, this form has been created for your convenience and information. WHAT YOU SHOULD EXPECT FROM US:

1) To see you as a person, not a condition. It is not our job to treat your symptoms or relieve them. Our job as a chiropractor is to find and correct the spinal health problems (vertebral subluxations) that are causing your symptoms.

2) Explain our procedures and findings, and then monitor and report your progress. 3) Show you ways to get and stay well. 4) Respect your privacy and time. 5) Honor your individual health goals. 6) Refer to other specialists as needed. 7) Charge a fair fee for our services.

WHAT WE EXPECT FROM YOU:

1) In order to reach your chiropractic goals, you must keep your appointments and participate in your healing. Your level of consistent participation will affect your outcome. If you need to cancel, please call us so we can reschedule you.

2) Once with the doctor, please do not answer your cell phone. Also, please limit wearing perfumes or cologne due to potential sensitivity of people in the office.

3) Want better health and follow our advice (exercises, stretches, nutritional, etc.). Healing is a process that takes time, and performance of any home exercises, activity modification or nutritional changes is recommended for best results.

4) Attend our Wellness Orientation Workshop (every Wednesday evening). This is presented for your benefit so that you will be able to make intelligent decisions regarding your health and your family’s health. Attendance is required for transition to the $89/mo Wellness Program.

5) Please pay your bill. 6) Tell others about the benefits of chiropractic care!

EVERY ADJUSTMENT APPOINTMENT – drinks LOTS of water. Ideally you should be drinking ½ your body weight in ounces per day (ex. 150 pound person needs 75 ounces of water). Drinking water will help minimize any type of soreness you may feel after your first adjustment, and is a crucial part of health and healing. Mama’s Chiropractic Clinic is a family practice. If you have children, bring them in for a check up. Do not wait until they are ill or hurt before they receive their first check up or adjustment. OFFICE HOURS: (subject to change – bold times are for Wellness Orientation Workshop) Monday: 2:00pm to 6:00 pm Tuesday: 9:00am- 12:00 pm and 2:00pm to 6:00 pm Wednesday: 2:00 pm to 6:00 pm Thursday: 9:00am- 12:00 pm and 2:00pm to 6:00 pm Friday: Available by Appointment Only Saturday: 9 am to 12:00 pm Sunday: Emergencies available by appointment only

Thank you for choosing us! I have read the expectations for care and understand what to expect from Mama’s Chiropractic, and what is expected of me. ______________________________ _________________________________

(Doctor) (Patient)

** last appointment taken 15 minutes prior

to closing**

Mama’s Chiropractic Clinic 3108 Del Prado Blvd S. Unit 6

Cape Coral, FL 33904 (239) 549-6262

Recurring Payment Authorization Form Schedule your payments to be automatically deducted from your bank account or charged to your Visa, MasterCard, American Express or Discover Card. Just complete and sign this form to get started! Recurring Payments Will Make Your Life Easier:

• It’s convenient (saving you time and postage) • Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period until the designated expiration date. A receipt will be emailed for each payment and the charge will appear on your bank or credit card statement. You will receive prior-notification 5 days before payment is due unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Once you have completed the initial care plan and attended the Wellness Orientation Workshop (W.O.W), you will be graduated to the $89/mo unlimited care plan. For administrative purposes, both of these billing schedules may be set up at the same time.

Please complete the information below: I _______________________ authorize Mama’s Chiropractic Clinic to charge my account indicated below (full name)

for (circle one) $200/$160/$140/$120/$150/$249/$299/$399 on the ________ of each month for payment of my 90 Day Unlimited, Pregnancy, or Family chiropractic care plan. I _______________________ authorize Mama’s Chiropractic Clinic to charge my account indicated below (full name)

for (circle one) $89/$178/$267/$299 on the ________ of each month for payment of my $89/mo Unlimited chiropractic care plan.

Billing Address ____________________________ Phone# ________________________

City, State, Zip ____________________________ Email ________________________

Checking/ Savings Account Credit Card

Checking Savings

Name on Acct ____________________

Bank Name ____________________

Last 4 of Acct # ____________________

Visa MasterCard

Amex Discover

Last 4 of Acct # _________________________

Exp. Date ____________

Authorization Expiration Date: ____________________________

SIGNATURE DATE My signature indicates I have read, understood, and agree to the terms and conditions regarding recurring payments printed on the reverse. I have been given a copy of these terms and conditions for my records. I understand that this authorization will remain in effect until the designated expiration date or until I cancel it in writing, whichever comes first, and I agree to notify Mama’s Chiropractic Clinic in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. I agree to surrender a 6% transaction fee if I ask for return after the amount is charged to my account. If the above noted payment dates falls on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Mama’s Chiropractic Clinic may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and agree not to dispute these scheduled payments with my bank or credit card company; provided the transactions correspond to the terms indicated in this authorization form. !

Mama’s Chiropractic Clinic 3108 Del Prado Blvd S. Unit 6

Cape Coral, FL 33904 (239) 549-6262

Recurring Payment Terms & Conditions • I!authorize!Mama's!Chiropractic!Clinic!to!debit!the!bank!account!or!credit!card!indicated!above!for!the!

amount!of!my!90!Day!Unlimited!Plan!on!the!reoccurring!monthly!schedule!indicated.!Once!completed,!I!

authorize!Mama’s!Chiropractic!Clinic!to!debit!the!bank!account!or!credit!card!indicated!above!for!the!

amount!of!my!$89!per!Month!Unlimited!Plan!($89/mo)!for!twelve!months!on!the!reoccurring!monthly!

schedule!indicated.!On!every!anniversary!of!this!agreement,!Mama's!Chiropractic!Clinic!has!my!consent!to!

renew!this!plan!for!twelve!months!until!it!is!canceled!by!either!party.!!This!payment!is!for!chiropractic!and!

related!health!care!services!and!I!desire!these!services!to!maintain!the!health!and!fitness!of!my!body.!!!

• I!understand!that!I!must!complete!and!pay!for!three!consecutive!months!of!care,!including!any!required!

examinations,!my!account!balance!must!be!current,!and!I!must!attend!the!W.O.W.!in!order!to!be!eligible!

for!the!$89/mo!Unlimited!Plan!offered!at!the!end!of!my!initial!program!of!care.!!I!understand!that!

discontinuing!care!by!stopping!payment!or!missing!three!consecutive!scheduled!appointments!will!end!

my!eligibility!for!either!program.!!I!agree!that!if!I!choose!to!resume!care!I!will!do!so!at!the!maximum!initial!

amount!for!one!month!and!pay!any!required!reOexam!fees,!at!which!point!my!eligibility!will!be!restored.!!I!

affirm!that!my!participation!in!both!the!90!Day!Unlimited/Pregnancy!Care/Family!and!the!$89/mo!

Unlimited!programs!are!strictly!voluntary,!and!agree!that!eligibility!requirements!and!determinations!are!

up!to!the!discretion!of!Mama's!Chiropractic!Clinic.!

• If!I!am!seeking!chiropractic!care!during!my!pregnancy,!I!understand!chiropractic!care!during!and!after!

pregnancy!is!nonOobstetrical!in!nature,!and!I!chose!these!services!for!the!health!and!fitness!of!my!body.!!!I!

understand!the!pregnancy!care!plan!rate!will!be!continued!until!I!have!completed!12!weeks!of!care!after!

the!delivery!of!my!child!(or!multiples),!and!that!12!weeks!after!my!first!postOpartum!visit!I!will!be!eligible!

for!the!$89/mo!Unlimited!Plan.!!I!understand!that!discontinuing!care!by!stopping!payment!or!missing!

three!consecutive!scheduled!appointments!will!end!my!eligibility!for!either!program.!!!

• I!agree!that!only!spouses!or!partners!and/or!dependent!children!qualify!for!the!Family!Plans,!and!all!

family!members!must!begin!within!30!days!to!be!eligible!for!the!2!and!3!or!More!Family!Discount!Plans.!!I!

understand!that!if!I!add!additional!family!members!while!I!am!under!the!Individual!or!$89/mo!plan,!their!

plan!will!be!added!to!my!autoOdebit!amount!until!those!new!family!members!have!also!earned!eligibility!

for!the!$89/mo!plan.!!I!understand!that!if!a!family!member!loses!their!eligibility!by!missing!three!

consecutive!appointments!or!discontinuing!care,!this!will!not!impact!the!other!family!members'!eligibility!

and!they!will!be!allowed!to!continue!at!the!$89/mo!rate.!!However,!if!that!family!member!returns!to!care,!

I!understand!we!will!return!to!the!original!additional!family!member!rate,!whichever!is!applicable,!until!

that!family!member's!eligibility!is!reOinstated.!!I!understand!that!the!$89/mo!eligibility!is!not!transferable!

between!family!members!and!once!all!family!members!are!eligible,!the!program's!maximum!cost!for!a!

family!of!4!or!more!is!$299/mo.!!!!!!!!

• I!understand!that!"unlimited"!visits!or!chiropractic!adjustments!are!dependent!on!office!hours!and!

schedule!availability.!!I!understand!that!examinations!and!adjustments!outside!of!normal!office!hours!are!

not!included!in!my!plan!and!must!be!paid!for!separately.!!!

• I!understand!that!returns,!refunds!and!cancellations!are!not!permitted,!however!exceptions!may!be!made!

on!a!caseObyOcase!basis!and!I!agree!to!surrender!a!6%!chargeOback!fee.!I!understand!that!this!

authorization!will!remain!in!effect!until!the!schedule!end!date,!or!until!I!cancel!it!in!writing!which!ever!

comes!first,!and!I!agree!to!notify!the!business!in!writing!of!any!changes!in!my!account!information!or!

termination!of!this!authorization!at!least!15!days!prior!to!the!next!billing!date.!If!the!above!noted!

payment!date!falls!on!a!weekend!or!holiday,!I!understand!that!the!payment!may!be!executed!on!the!next!

business!day.!I!understand!that!because!this!is!an!electronic!transaction,!these!funds!may!be!withdrawn!

from!my!account!each!period!as!soon!as!the!above!noted!transaction!date.!!

• In!the!case!of!an!ACH!Transaction!being!rejected!for!Non!Sufficient!Funds!(NSF)!I!understand!that!the!

business!may!at!its!discretion!attempt!to!process!the!charge!again!within!30!days,!and!agree!to!an!

additional!$35.00!charge!for!each!attempt!returned!NSF!which!will!be!initiated!as!a!separate!transaction!

from!the!authorized!recurring!payment.!I!acknowledge!that!the!origination!of!ACH!transactions!to!my!

account!must!comply!with!the!provisions!of!U.S.!law.!!

• I!certify!that!I!am!an!authorized!user!of!this!credit!card!or!bank!account,!and!that!I!will!not!dispute!the!

payment!with!my!Credit!Card!Company!or!Bank,!so!long!as!the!transaction!corresponds!to!the!terms!

indicated!above.!

!

Mama’s&Chiropractic&Clinic&&

3108&Del&Prado&Blvd&S&Unit&6&&

Cape&Coral,&FL&33904&&

Phone:&(239)&549H6262&Fax:&(239)&676H0111&

www.mamaschiropractic.com&

!Explanation!and!Comparison!of!Discounts!and!Plans!While!most!offices!run!on!a!fee8for8service!basis,!our!practice!functions!on!a!different!model!that!makes!payments!fair!and!affordable!for!families!and!rewards!them!for!being!proactive!with!their!health.!The!concept!is!pretty!simple:!Our!usual!fees!are!$50!per!visit,!but!by!offering!discounts!for!joining!the!auto8debit!program!most!of!our!patients!actually!pay!less!for!a!year!of!care!than!they!would!if!we!were!in!their!insurance!network.!We!see!our!patients!more!frequently!the!first!90!days!to!get!their!nerve!systems!up!and!running.!!We!know!that!when!patients!continue!their!care!after!the!initial!90!days!they’re!less!likely!to!have!flare8ups.!!So!for!patients!who!attend!our!Wellness!Orientation!Workshop!we!offer!a!discount!on!unlimited!monthly!care!($89/mo)!for!maintenance.!!We!typically!see!these!patients!every!two!weeks!with!our!promise!that!if!they!need!a!booster,!they’ll!be!covered!without!any!extra!cost.!!!During!pregnancy!we!see!our!moms!more!frequently!before!and!after!the!due!date.!!So!for!expecting!mothers,!Mama’s!Chiropractic!Clinic!offers!a!special!program!that!includes!unlimited!visits!until!90!days!after!baby’s!arrival!for!$150/mo.!!Newborns!may!be!added!for!$99/mo.!!At!the!completion!of!the!program,!these!mothers!and!babies!will!then!be!invited!to!participate!in!the!$89!a!month!plan.!We!also!encourage!families!to!start!care!together!by!offering!discounted!two8person!and!family!plans!for!families!who!join!within!the!same!month.!!A!smaller!discount!applies!if!family!members!are!added!after!the!initial!30!days.!!!Service! Amount!New!Patient!Consult!&!Exam! $100!Single!Adjustment!or!Emergency!Visit!Outside!Office!Hours! $50!Quarterly!Patient!Update!Exam! $25!Food!Sensitivity!Testing! $45!Established!Patient!Exam!(Patient!absence!of!longer!than!a!6!months!or!new!major!trauma!requiring!re8evaluation)!

$60!

!!Each!Plan!Type!Includes!Unlimited!Adjustment!Appointments!1!

Monthly!Auto8Debit!Amount!

Budgeting!for!90!Day!Total!Cost!

Estimated!Pay!As!You!Go!(16!visits!over!3!mo)! N/A! $800!Pregnancy!Care!Plan!! $150! $450!PP2!Individual!90!Day!Plan! $200! $600!2nd!Family!Member!90!Day!Plan!! $160! $480!(20%!off)!3rd!Family!Member!90!Day!Plan!! $140! $420!(30%!off)!4th!&!Additional!Family!Members!90!Day!Plan! $120! $360!(40%!off)!!Special!Rate!for!Families!Who!All!Start!Within!30!Days!of!the!First!Family!Member!

Monthly!Auto8Debit!Amount!

Budgeting!for!90!Day!Total!Cost!

Newborn!Addition!to!Existing!Pregnancy!Plan! $99+$150! $297+$450!Two!Person!Family!90!Day!Plan! $299! $897!Three!or!More!Family!90!Day!Plan! $399! $1197!!90!Day!Program!Graduates!are!Eligible!for!the!Following!Plans:! !Unlimited!Individual!Chiropractic!Maintenance!Program! $89!per!month!Unlimited!Two!Person!Family!Maintenance!Program! $178!per!month!Unlimited!Three!Person!Family!Maintenance!Program! $267!per!month!Unlimited!Four!+!Person!Family!Maintenance!Program! $299!per!month!!1.!!Exams,!Re8exams,!and!Food!Sensitivity!Testing!are!not!included!in!the!auto8debit!amounts.!!2.!!Pregnancy!program!has!no!minimum!length!of!care,!although!rate!continues!for!3!payments!of!$150!post!partum.!!!