PATIENT TYPE 1 [ONE]
DR MICHEL RICE
DC AADEP FCCS(S) ASSOCIATE MD
DO NOT SIGN (FILL-IN) UNLESS YOU ARE
IN THE CLINIC & IN THE PRESENCE OF YOUR PAIN THERAPY PRACTITIONER.
THIS INFORMED CONSENT MUST BE EXPLAINED
TO YOU IN PERSON BY THE DOCTOR OR PAIN THERAPY PRACTITIONER [PTP]
THE INFORMED CONSENT & INJURY RELEASE
CONSENT TO TREATMENT FOR
PATIENT TYPE 1 [ONE]
INTENTION OF THIS INFORMED CONSENT
We request your understanding in maintaining both your and our safety by reading and signing the following INFORMED CONSENT AGREEMENT & INJURY RELEASE.
I, as the patient, am aware that all activities, treatments, services and programs offered are either therapeutic, educational, recreational, or self-directed in nature.
I assume full responsibility during and after my treatment participation for my choices to use or apply, at my own risk, any portion of the information or instruction I receive from a BCD INC (Better Call Doc INC) , Sexy Back or a Brave Health practitioner.
ARE YOU A PATIENT TYPE ONE?
THE BETTER CALL DOC INC (BCD INC) PATIENT: BCD INC PATIENTS EXAMINED BY BCD INC DOCTOR OF CHIROPRACTIC.
PATIENT TYPE ONE IS ALSO A PATIENT WHO IS RECEIVING DIRECT CARE FROM DR. RICE FOR SPINAL MANIPULATION AND/OR MOBILIZATION AS WELL AS OTHER CARE OF AN NMS NATURE (NEURO-MUSCULO-SKELETAL) THAT FALL UNDER DR. RICE’S MEDICAL SPECIALTIES (IMPAIRMENT EVALUATION, DOCTOR OF CHIROPRACTIC OR SPORTS CHIROPRACTIC AS AN ASSOCIATE MEMBER OF THE FELLOWSHIP).
ABOUT CHIROPRACTIC SPINAL MANIPULATION (SMT) (PATIENT TYPE ONE)
ABOUT RISK OF HARM (COLLEGE OF CHIROPRACTORS AND CANADIAN CHIROPRACTIC PROTECTIVE PLAN ASSIGNED INFORMED CONSENT)
Any physician or chiropractor who performs SMT (spinal manipulative therapy) on a cervical spine (neck) must advise his/her patient on the possibility of injury to the vertebral artery during the course of treatment. Injury to the vertebral artery may cause strokes or stroke-like occurrences, which are usually of a temporary nature. The chances of this injury happening are between one in one million and one in one and a half million. Tests will be performed on you to minimize this risk to yourself. Chiropractic is considered to be one of the safest and most effective forms of health care in the world. If you have any questions about this, please ask Dr. Rice.
There are 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 progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote.
While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures. As in all medical procedures, the risk-benefit ratios must be deemed favourable for the patient and in my case, I understand that Dr. Rice will evaluate my condition, review the risks, if any, and will inform me if risks fall beyond the limits of this informed consent prior to treating me.
There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment;
There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy.
I have read and understand the risks described above in this subsection for chiropractic treatment by a doctor of chiropractic as required & written by the College of Chiropractors of Ontario. My signature below confirms my understanding, acknowledgment & consent to treatment as a patient Type One.
ABOUT BCD INC HEALTH PRACTITIONERS:
CHIROPRACTORS AND PHYSIOTHERAPISTS
Must be licensed professionals by their respective colleges. Must be trained and certified by the BCD INC SYSTEM OF PATIENT CARE AND MANAGEMENT prior to commencing direct unsupervised BCD INC patient care.
BCD INC THERAPY & MANAGEMENT PAIN THERAPY PRACTITIONERS [PTP]
Must be licensed and independently insured professionals with one of the following degrees: kinesiology, fitness trainer, massage therapist, Bachelor of Physical Education, Personal Support Worker. Must be trained and certified by the BCD INC SYSTEM OF PATIENT CARE AND MANAGEMENT prior to commencing direct unsupervised BCD INC patient care.
I understand that BCD INC [PTP]'S are certified by the BCD INC chief primary care physician, Dr. Michel Rice. I also understand that all treatments involve safe therapeutic modalities (pain management and exercise) that can be used by myself at home independently (Home care Type Therapy). BCD INC, Sexy Back and Brave Health programs principally involve responsibilities of guidance, adherence to pain management, monitoring of dosage of care, adherence to active rehabilitation participation rates and feedback monitoring systems that may also work in collaboration with my primary care physician (MD).
This subsection requires my signing the Patient Type Two (2) informed consent entitled 'Already Saw Doc' with all of its detailed acknowledgments for this type of patient.
BCD INC BRAVE HEALTH ACTIVE THERAPY PRACTITIONERS
Must be licensed and independently insured fitness professionals with one of the following degrees: kinesiology, fitness trainer, Bachelor of Physical Education, Personal Support Worker.
Must be trained and certified by the BCD INC/Brave Health SYSTEM OF PATIENT CARE AND MANAGEMENT prior to commencing direct unsupervised Brave Health Active Therapy treatments with the patient.
This subsection requires my signing the Patient Type Three (3) informed consent entitled 'Brave Health Active Therapy - Brave Rehab' with all of its detailed acknowledgments for this type of patient.
HEALTH POLICY FINANCIAL TERMS
CREDIT CARD MONTHLY AUTHORIZATION POLICY
I authorize Better Call Doc INC to process my credit card on a monthly basis for my single visit treatments or my monthly membership fees (treatment plan) involving Patient Types 1, 2 or 3. I UNDERSTAND THAT I CANNOT RECEIVE 'CREDIT' FOR ANY VISITATION THAT I HAVE NOT USED FROM MY MONTHLY MEMBERSHIP PLAN. If I do, Better Call Doc INC will re-calculate the monthly utility rate at single visitation costs following the respective provincial college recommendation and I agree to BCD INC’s invoicing for the smaller of the monthly total sum.
Better Call Doc INC acknowledges that monthly memberships for unused services cannot be enforced to a patient or client. Better Call Doc INC will then reserve the right to terminate the monthly treatment plan based upon my not supporting the monthly commitment and/or not using the membership treatment privileges. I understand that there are extra fees involving medicinal transdermal OTC medicines at $2 per mg/ml. I also understand that there may be other surcharges for treatments involving medical appliances and supports. All additional charges will be advised before treatment is applied on a first-application basis only.
I understand that BCD INC, Sexy Back and Brave operates as a clinic. Brave, Sexy Back and BCD INC are entitled to close, with 2 weeks’ notice, for no longer than one week at a time with a maximum of 6 weeks per year. Monthly membership fees are calculated based upon a 6 week absence per yea. These holidays involve treatment and examining practitioners. I understand that my care plan will allow for home-type care instructions which will be provided to me by a BCD INC practitioner.
I understand that BCD INC re-evaluations for any of my injuries or impairments have additional examination fees which are $62 to $140 per examination. The examinations are conducted by Dr. Rice. Tele-medicine re-evaluations with Dr. Rice also have a fee of $62 per consult. I will be advised of fee structures prior to the actual consult / examination. Fees may be adjusted without notice or reflection on this informed consent.
I understand that as a member of Sexy Back, I must pay a total of $10 per month to maintain my membership accessibility to the facilities in Timmins ON. This fee does not allow me to use the facilities independently. I must have a fitness practitioner, Pain Therapy Practitioner [PTP], or a doctor with me at all times. The fee also includes all Sexy Back classes where I can attend in person at the clinic on the SIXTH.
ABOUT INSURANCE BILLING AND PAYMENT FOR PATIENT TYPE 1 UNDER DIRECT CARE OF DR. RICE FOR CONSULTATION, PHYSICAL EXAMINATION, SPINAL MANIPULATION AND MOBILIZATION
I understand and agree that health benefit and accident insurance policies are an arrangement between an insurance carrier and myself as the patient.
Furthermore, I understand that Dr. Rice will prepare any necessary reports and form to assist me in making collection from my insurance company. Fees may apply for reports - form fill-out tasks, which are $35 per form.
I understand that I am to pay Dr. Rice’s clinic directly using a credit card FOR ALL BCD INC. SERVICES. A receipt will be provided immediately after processing my personal insurance submission. I understand that BCD INC operates from its main office in Toronto ON.
I also understand that Better Call Doc INC. will securely keep my credit card information [MEGA Medical encryption] safely and I can also pay for individual services directly using the Better Call Doc INC. website.
I also understand that if I suspend or terminate care, any fees for professional services rendered to me will be immediately processed on my credit card and a receipt of the said paid balance will be provided for me at the time of the payment.
FINAL ACKNOWLEDGMENT AND CONSENT
I hereby authorize Dr. Rice to treat my condition as he deems appropriate with spinal manipulation or any other therapeutic modalities deemed necessary.
I hereby and hold harmless Dr. Michel Rice, Chief of BCD INC, Sexy Back and Brave Health Clinical Operations, it’s agents, officers, health practitioners, fitness practitioners and employees and any affiliated companies from any liability with respect to any causes of action, claims, damages, loss or injury of any nature to me or my property arising out of, or connected with my exercise participation or therapeutic involvement with Better Call Doc INC associates.
I acknowledge that I have read this consent and I have discussed or have been offered the opportunity to discuss, with Dr. Rice or his associates (pain therapy practitioner, fitness trainer), the nature and purpose of chiropractic treatment in general. The treatment options and recommendations for my condition, and the contents of this Consent.
I consent to the treatment recommended to me by my chiropractor including any recommended spinal adjustments. If I choose to not have spinal manipulation or if I choose to be an Already Called Doc Patient Type 2, I consent to treatment recommendations as per the BCD INC Care Practitioner (Pain Therapy Practitioner) who will follow home-type care only and function fully under the BCD INC accreditation and license of the Chief of Operations, Dr. Michel Rice, as a doctor of chiropractic.
This consent applies to all my present and future chiropractic care, BCD INC care practitioner treatments and/or Brave Health Active Fitness Practitioner treatments.
ADDITIONAL SIGNING MAY BE REQUIRED
PLEASE SIGN INFORMED CONSENT TYPE TWO 'ALREADY SAW DOC' IF YOU ARE EXEMPT FROM A COMPREHENSIVE EXAMINATION (FORM 3B)
PLEASE SIGN INFORMED CONSENT TYPE THREE 'BRAVE REHAB' IF YOU ARE PARTICIPATING IN ACTIVE THERAPY WITH YOUR FITNESS TRAINER WHO IS REGISTERED WITH BETTER CALL DOC INC. (FORM 3C)