Common use of Surgery Clause in Contracts

Surgery. If you 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 care physician. Remaining untreated may allow the formation of 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 efficient the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. I have read ( ) or have had to read to me ( ) the above explanation of the chiropractic adjustment and related treatment. I have discussed with Xx. Xxxxxxxxx and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that is it in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. Dated: Dated: Patients name: Doctor's name: Signature: Signature: Signature of parent or guardian (if a minor): THIS AGREEMENT is made between LAKEWOOD CHIROPRACTIC, their physicians, agents, employees, servants, or any of the foregoing, 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 there are numerous other physicians in Northeast Florida who are qualified to do physical medicine. It is further understood, that in the event of 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 chose 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 care medical physician. Remaining untreated may allow the formation of adhesive 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 efficient effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVEI, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. As of this date, I have read ( 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. I, have read, or have had to read to me ( ) me, the above explanation of the chiropractic adjustment Chiropractic Manipulative Therapy / Adjustment and related treatmentCare. I have discussed it with Xx. Xxxxxxxxx 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 treatment Care and have decided that it is it in my best interest to undergo the treatment recommendedCare as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to that treatmentsuch Care. Dated: Dated: Patients name: Doctor's name: Patient’s Signature: / / / / Person 2’s Signature: Signature / / / _/ 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: / / 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 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 parent or guardian (if a minor): THIS AGREEMENT is made between LAKEWOOD CHIROPRACTICage, their physicians, agents, employees, servants, or any of the foregoing, 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 there are numerous other physicians in Northeast Florida who are qualified to do physical medicine. It 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) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at □ 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 further understood, that in the event of 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 Student at the arbitration hearing.□ FULL-TIME □PART-TIME

Surgery. If you chose 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 care medical physician. Remaining untreated may allow the formation of adhesive 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 efficient effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVEI, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. As of this date, I have read ( 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. I, have read, or have had to read to me ( ) me, the above explanation of the chiropractic adjustment Chiropractic Manipulative Therapy / Adjustment and related treatmentCare. I have discussed it with Xx. Xxxxxxxxx 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 treatment Care and have decided that it is it in my best interest to undergo the treatment recommendedCare as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to that treatmentsuch Care. Dated: Dated: Patients name: Doctor's name: Patient’s Signature: / / / / Person 2’s Signature: Signature of parent or guardian (if a minor): THIS AGREEMENT is made between LAKEWOOD CHIROPRACTIC/ / / _/ By signing below, their physicians, agents, employees, servants, or any of I attest that I thoroughly discussed this Document and Care with the foregoing, 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 there are numerous other physicians in Northeast Florida who are qualified to do physical medicine. It is further understood, that in the event of 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 above-referenced individual(s) prior 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 time this Document was signed 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 such individual(s) at the arbitration hearing.Office. Provider’s Signature: / /

Surgery. If you chose 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 care medical physician. Remaining untreated may allow the formation of adhesive 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 efficient effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVEPre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 1 I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. As of this date, I have read ( 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. I, have read, or have had to read to me ( ) me, the above explanation of the chiropractic adjustment Chiropractic Manipulative Therapy / Adjustment and related treatmentCare. I have discussed it with Xx. Xxxxxxxxx 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 treatment Care and have decided that it is it in my best interest to undergo the treatment recommendedCare as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to that treatmentsuch Care. Dated: Dated: Patients name: Doctor's name: Patient’s Signature: / / / / Person 2’s Signature: Signature / / / _/ 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: / / 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 parent 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 guardian 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. 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! 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 Street: City: State: _ Zip: Mobile Phone: Home Phone: Email: How did you hear about us / who referred you to us? If Advertisement (if a minor): THIS AGREEMENT is made between LAKEWOOD CHIROPRACTICTV, their physiciansRadio, agentsEtc.), employeesAny Promo Code or Name? If Internet Search, servantsWhat Query Did You Use? ========================================================================================================= If you are under 18 years of age, or any of the foregoing, 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 there are numerous other physicians in Northeast Florida who are qualified to do physical medicine. It 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) Street: City: State: _ Zip: Your Profession: Your Employer: Your Work Address: Student at □ 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 further understood, that in the event of 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 Student at the arbitration hearing.□ FULL-TIME □PART-TIME

Surgery. If you chose 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 care medical physician. Remaining untreated may allow the formation of adhesive 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 efficient effective the longer it is postponed. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVEPre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 1 I, the below-signed (see “Person 2” below), hereby request and authorize the Care as set forth above to my minor son/daughter/xxxx. PLEASE CHECK THE APPROPRIATE BOX AND SIGN BELOW. As of this date, I have read ( 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. I, have read, or have had to read to me ( ) me, the above explanation of the chiropractic adjustment Chiropractic Manipulative Therapy / Adjustment and related treatmentCare. I have discussed it with Xx. Xxxxxxxxx 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 treatment Care and have decided that it is it in my best interest to undergo the treatment recommendedCare as recommended or determined in the Doctors’ discretion. Having been informed of the risks, I hereby give my consent to that treatmentsuch Care. Dated: Dated: Patients name: Doctor's name: Patient’s Signature: / / / / Person 2’s Signature: Signature of parent or guardian (if a minor): THIS AGREEMENT is made between LAKEWOOD CHIROPRACTIC/ / / _/ By signing below, their physicians, agents, employees, servants, or any of I attest that I thoroughly discussed this Document and Care with the foregoing, 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 there are numerous other physicians in Northeast Florida who are qualified to do physical medicine. It is further understood, that in the event of 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 above-referenced individual(s) prior 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 time this Document was signed 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 such individual(s) at the arbitration hearing.Office. Provider’s Signature: / / Pre-Day-1 Medical Forms | Applicable Healthcare Providers | Section Page 2 Name: Date: Use the letters below to indicate the type and location of your sensations you are feeling right now: