Common use of Surgery Clause in Contracts

Surgery. If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. CONSENT TO TREATMENT (MINOR). I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. As of this date, I have the legal right to select and authorize healthcare services for the minor child / xxxx named below. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize Care should be revoked or modified in any way, I will immediately notify the Office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I, have read, or have had read to me, the above explanation of the Chiropractic Manipulative Therapy / Adjustment and related Care. I have discussed it with the Doctor(s) at the Office and have had my questions answered to my satisfaction. By signing this Informed Consent Document below, I state that I have weighed the risks involved in undergoing Care and have decided that it is in my best interest to undergo the Care as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to such Care. Patient’s Signature: / / / / Patient Full Name – Date of Signature Date of Signature at Office Person 2’s Signature: / / / _/ Person Full Name – Date of Signature Date of Signature at Office OFFICE USE ONLY: By signing below, I attest that I thoroughly discussed this Document and Care with the above-referenced individual(s) prior to the time this Document was signed by such individual(s) at the Office. Provider’s Signature: / / Provider’s Full Name – Date of Signature at the Office “New Patient Information Forms” Patient’s Full Name: Today's Date: / / _ Social Security Number: Birth Date: / / Age: Gender: F M O Marital Status: Married Separated Widowed Significant Other Single CURRENT ADDRESS Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you to us? If Advertisement (TV, Radio, Etc.), Any Promo Code or Name? If Internet Search, What Query Did You Use? ========================================================================================================= If you are under 18 years of age, who are your legal parents or guardian? Father Date of Birth: / / (m) (h) Mother Date of Birth: / / (m) (h) Legal Guardian / Xxxxxx Parent Date of Birth: / / (m) (h) ANY OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at Your Work Phone: □ FULL-TIME □PART-TIME Name of Spouse: Spouse's Date of Birth: / / Spouse’s Profession: Spouse’s Employer: Spouse’s Work Address: Spouse’s Work Phone: Spouse is a Student at □ FULL-TIME □PART-TIME Who should we contact in the event of an emergency? Mobile Phone: Home Phone: Email:

Surgery. If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. CONSENT TO TREATMENT (MINOR). I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. As of this date, I have the legal right to select and authorize healthcare services for the minor child / xxxx named below. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize Care should be revoked or modified in any way, I will immediately notify the Office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I, have read, or have had read to me, the above explanation of the Chiropractic Manipulative Therapy / Adjustment and related Care. I have discussed it with the Doctor(s) at the Office and have had my questions answered to my satisfaction. By signing this Informed Consent Document below, I state that I have weighed the risks involved in undergoing Care and have decided that it is in my best interest to undergo the Care as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to such Care. Patient’s Signature: / / / / Patient Full Name – Date of Signature Date of Signature at Office Person 2’s Signature: / / / _/ Person Full Name – Date of Signature Date of Signature at Office OFFICE USE ONLY: By signing below, I attest that I thoroughly discussed this Document and Care with the above-referenced individual(s) prior to the time this Document was signed by such individual(s) at the Office. Provider’s Signature: / / Provider’s Full Name – Date of Signature at the Office “New Patient Information Forms” Patient’s Full NameTerms of Healthcare Services FWCC, Other Applicable Healthcare Providers, and Accounts Servicing Center Form ID: Today's Date: / / _ Social Security Number: Birth Date: / / Age: Gender: F M O Marital Status: Married Separated Widowed Significant Other Single CURRENT ADDRESS Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you to us? If Advertisement (TV, Radio, Etc.), Any Promo Code or Name? If Internet Search, What Query Did You Use? ========================================================================================================= If you are under 18 years of age, who are your legal parents or guardian? Father Date of Birth: / / (m) (h) Mother Date of Birth: / / (m) (h) Legal Guardian / Xxxxxx Parent Date of Birth: / / (m) (h) ANY OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at Your Work Phone: □ FULLTerms-TIME □PARTof-TIME Name of Spouse: Spouse's Date of Birth: / / Spouse’s Profession: Spouse’s Employer: Spouse’s Work Address: Spouse’s Work Phone: Spouse is a Student at □ FULLHealthcare-TIME □PARTServices-TIME Who should we contact in the event of an emergency? Mobile Phone: Home Phone: Email:FWCC-Texas-Fort-Worth-BON-0001-27 ----------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- SECTION – HIPAA CONSENT FORM -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------

Surgery. If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Pre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 1 CONSENT TO TREATMENT (MINOR). I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. As of this date, I have the legal right to select and authorize healthcare services for the minor child / xxxx named below. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize Care should be revoked or modified in any way, I will immediately notify the Office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I, have read, or have had read to me, the above explanation of the Chiropractic Manipulative Therapy / Adjustment and related Care. I have discussed it with the Doctor(s) at the Office and have had my questions answered to my satisfaction. By signing this Informed Consent Document below, I state that I have weighed the risks involved in undergoing Care and have decided that it is in my best interest to undergo the Care as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to such Care. Patient’s Signature: / / / / Patient Full Name – Date of Signature Date of Signature at Office Person 2’s Signature: / / / _/ Person Full Name – Date of Signature Date of Signature at Office OFFICE USE ONLY: By signing below, I attest that I thoroughly discussed this Document and Care with the above-referenced individual(s) prior to the time this Document was signed by such individual(s) at the Office. Provider’s Signature: / / Provider’s Full Name – Date of Signature at the Office Pre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 2 New PI Patient Chart‌‌‌‌‌ Dear Patient: Please take time to complete all attached information. One of our goals is to help ensure you receive the care you need at no out-of-pocket* expense to you. But another goal is to help ensure that when your case settles or is resolved, all of your bills at our office have been properly covered. We’ve been successful helping many other patients accomplish these goals, BUT WE NEED YOUR HELP. The more information you can provide us, the greater the chances that we will be able to help you. Accident coverage can be complex. Ask for My Business Card! Xxxxxx Xxxx Clinic PI Administrator 000-000-0000 If you have any questions, please do not hesitate to ask. We are here to help guide you through the process! Sincerely Your Clinic PI Admin Team! “New Patient Information Forms” Patient’s Full Name: Today's Date: / / _ Social Security Number: Birth Date: / / Age: Gender: F M O Marital Status: Married Separated Widowed Significant Other Single CURRENT ADDRESS Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you to us? If Advertisement (TV, Radio, Etc.), Any Promo Code or Name? If Internet Search, What Query Did You Use? ========================================================================================================= If you are under 18 years of age, who are your legal parents or guardian? Father Date of Birth: / / (m) (h) Mother Date of Birth: / / (m) (h) Legal Guardian / Xxxxxx Parent Date of Birth: / / (m) (h) ANY OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at Your Work Phone: □ FULL-TIME □PART-TIME Name of Spouse: Spouse's Date of Birth: / / Spouse’s Profession: Spouse’s Employer: Spouse’s Work Address: Spouse’s Work Phone: Spouse is a Student at □ FULL-TIME □PART-TIME Who should we contact in the event of an emergency? Mobile Phone: Home Phone: Email:

Surgery. If you choose chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical care physician. The risks and dangers attendant to remaining untreated. untreated Remaining untreated may allow the formation of adhesions adhesive and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective efficient the longer it is postponed. CONSENT TO TREATMENT (MINOR). I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. As of this date, I have the legal right to select and authorize healthcare services for the minor child / xxxx named below. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize Care should be revoked or modified in any way, I will immediately notify the Office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I, PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. I have read, read ( ) or have had to read to me, me ( ) the above explanation of the Chiropractic Manipulative Therapy / Adjustment chiropractic adjustment and related Caretreatment. I have discussed it with the Doctor(s) at the Office Xx. Xxxxxxxxx and have had my questions answered to my satisfaction. By signing this Informed Consent Document below, I state that I have weighed the risks involved in undergoing Care treatment and have decided that is it is in my best interest to undergo the Care as recommended or determined in the Doctors’ discretiontreatment recommended. Having been informed of the risks, I hereby give my consent to such Carethat treatment. Patient’s Dated: Dated: Patients name: Doctor's name: Signature: / / / / Patient Full Name – Date of Signature Date of Signature at Office Person 2’s Signature: / / / _/ Person Full Name – Date Signature of Signature Date parent or guardian (if a minor): LAKEWOOD CHIROPRACTIC 0000 Xxxxxxxxxx Xxxx. West, Jacksonville, FL 32217 Telephone (000) 000-0000 NOTICE OF WAIVER AND RELEASE CONCERNING MEDICAL NEGLIGENCE INSURANCE. THIS AGREEMENT is made between LAKEWOOD CHIROPRACTIC, their physicians, agents, employees, servants, or any of Signature at Office OFFICE USE ONLY: By signing belowthe foregoing, I attest referred hereinafter as “Doctor” and , referred to hereinafter as the “Patient”. It is the intention of the parties to this agreement to bind not only themselves, but also their heirs, personal representatives, guardians or any persons deriving claims through or on behalf of the patient. It is understood by the patient the he or she is not required to use the aforesaid practice or any physician named for physical medicine and that I thoroughly discussed this Document and Care with the above-referenced individual(s) prior to the time this Document was signed by such individual(s) at the Office. Provider’s Signature: / / Provider’s Full Name – Date of Signature at the Office “New Patient Information Forms” Patient’s Full Name: Today's Date: / / _ Social Security Number: Birth Date: / / Age: Gender: F M O Marital Status: Married Separated Widowed Significant Other Single CURRENT ADDRESS Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you to us? If Advertisement (TV, Radio, Etc.), Any Promo Code or Name? If Internet Search, What Query Did You Use? ========================================================================================================= If you there are under 18 years of age, numerous other physicians in Northeast Florida who are your legal parents or guardian? Father Date of Birth: / / (m) (h) Mother Date of Birth: / / (m) (h) Legal Guardian / Xxxxxx Parent Date of Birth: / / (m) (h) ANY OTHER ADDRESSES WHERE YOU RESIDE (e.g.qualified to do physical medicine. It is further understood, parents' home, any other address where you regularly reside) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at Your Work Phone: □ FULL-TIME □PART-TIME Name of Spouse: Spouse's Date of Birth: / / Spouse’s Profession: Spouse’s Employer: Spouse’s Work Address: Spouse’s Work Phone: Spouse is a Student at □ FULL-TIME □PART-TIME Who should we contact that in the event of an emergency? Mobile Phone: Home Phone: Email:any controversy or dispute, which might arise between the Doctor and the patient, regardless of whether the dispute concerns the medical care rendered, including any negligence claim relating to the diagnosis, treatments or care of the patient, or payment of medical fees, or any other matter whatsoever, then the parties agree that the dispute shall be resolved by arbitration as provided by the Florida Arbitration Code, Chapter 682 (Florida Statutes). This arbitration shall be in lieu and instead of any trial by Judge or Jury. Each party shall choose one arbitrator and the two arbitrators shall choose a third arbitrator. The panel of arbitrators shall hear and decide the controversy, and the decision shall be binding on all parties and may be forced by a court of law necessary. In the event that either party to this agreement refuses to go forward with arbitration, the party compelling arbitration reserves the right to proceed with arbitration, the appointment of the arbitrator and hearings to resolve the dispute, despite the refusal to participate of the absence of the opposing party. The Arbitrator shall go forward with the arbitration hearing and render a binding decision without the participation of the party opposing arbitration or dispute his or her absence at the arbitration hearing.

Surgery. If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Pre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 1 CONSENT TO TREATMENT (MINOR). I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. As of this date, I have the legal right to select and authorize healthcare services for the minor child / xxxx named below. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize Care should be revoked or modified in any way, I will immediately notify the Office. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I, have read, or have had read to me, the above explanation of the Chiropractic Manipulative Therapy / Adjustment and related Care. I have discussed it with the Doctor(s) at the Office and have had my questions answered to my satisfaction. By signing this Informed Consent Document below, I state that I have weighed the risks involved in undergoing Care and have decided that it is in my best interest to undergo the Care as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to such Care. Patient’s Signature: / / / / Patient Full Name – Date of Signature Date of Signature at Office Person 2’s Signature: / / / _/ Person Full Name – Date of Signature Date of Signature at Office OFFICE USE ONLY: By signing below, I attest that I thoroughly discussed this Document and Care with the above-referenced individual(s) prior to the time this Document was signed by such individual(s) at the Office. Provider’s Signature: / / Provider’s Full Name – Date of Signature at the Office “New Patient Information Forms” Patient’s Full Pre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 2 Fort Worth Chiropractic Clinic, PLLC Pain Questionnaire Name: Today's Date: / / _ Social Security Number: Birth Date: / / Age: Gender: F M O Marital Status: Married Separated Widowed Significant Other Single CURRENT ADDRESS Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you Use the letters below to us? If Advertisement (TV, Radio, Etc.), Any Promo Code or Name? If Internet Search, What Query Did You Use? ========================================================================================================= If indicate the type and location of your sensations you are under 18 years of age, who are your legal parents or guardian? Father Date of Birth: / / (m) (h) Mother Date of Birth: / / (m) (h) Legal Guardian / Xxxxxx Parent Date of Birth: / / (m) (h) ANY OTHER ADDRESSES WHERE YOU RESIDE (e.g., parents' home, any other address where you regularly reside) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at Your Work Phone: □ FULL-TIME □PART-TIME Name of Spouse: Spouse's Date of Birth: / / Spouse’s Profession: Spouse’s Employer: Spouse’s Work Address: Spouse’s Work Phone: Spouse is a Student at □ FULL-TIME □PART-TIME Who should we contact in the event of an emergency? Mobile Phone: Home Phone: Emailfeeling right now: