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SoftWave Therapy Intake Form

Source Family Chiropractic

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PLEASE READ THE PRE-TREATMENT GUIDELINES BEFORE YOU CONTINUE FILLING OUT THE FORM

Pre-Treatment Guidelines

Very Important A: Please refrain from taking any NSAID class drugs (Advil, ibuprofen, Motrin, aspirin, naproxen, etc.) orally or topically at least 2 days prior to your treatment and a minimum of 2 days after your treatment. It is optimal not to take these at all during your series. Non-NSAID pain relievers (Tylenol, Tramadol, narcotics) are OK to take. Natural anti-inflammatories such as Curcumin, healthy omega oils, and other natural health supplements are OK. Baby aspirin for heart health is OK, but higher doses are not recommended due to blood thinning action. Other than NSAIDs, DO NOT discontinue any of your regular medications. Talk to your medical doctor if you have special concerns.

Very Important B: Hydration! Make sure to be fully hydrated for 2 days prior to your appointment. Take your body weight, divide it in half… that is the number of ounces of water you should drink daily. It is important to drink clean water with balanced electrolytes. (i.e. A 200 lb person (50% of 200 = 100) would drink 100 ounces of water daily) If you are dehydrated, it decreases the effectiveness of the treatment. The success of this treatment rests on harnessing and focusing your body's ability to heal, so be sure to set the stage for your success.

For the safety and comfort of our patients and staff, Source Family Chiropractic is a Fragrance-Free Zone. DO NOT wear any perfume, cologne, scented lotions, scented hair products, or clothing washed with scented fabric softener on the day of your treatment.

Please do not attempt to sedate yourself by taking pain medications that you are not accustomed to, or worse, a cocktail of medications prior to your treatment. It is very important that you are alert and able to feel and give the doctor feedback during your treatment in order to target your best therapeutic dose. While there may be minimal pain with your treatment, your doctor will communicate with you continually and adjust intensity so that you have a good experience, and nothing will go over your threshold of comfort.

Please do not attempt any multi-day fasts, either directly before or directly after your treatment. Multi-day fasting can put your body in a vulnerable state which can lead to post-treatment recovery complications. Do make sure to be well rested, eat well, and avoid sugar and alcohol.

Wear loose comfortable clothing that is easy to take off and put on, try to wear slip-on shoes if possible. If you are having treatment for a knee or hip, yoga pants, tights, or tapered ankle pants will require you to change into our gowns and shorts.

If you have high blood pressure, it is a good idea to monitor your pressure for a few days in advance of your appointment. If necessary, do a medication check with your doctor before your treatment. If your blood pressure is uncontrolled, we may have to postpone your treatment for your safety.

Have realistic expectations and be patient. While we are happy to report that our overall results are excellent, it is important to know that this treatment does not help everyone. Although many patients feel amazing changes in the first few sessions, initial reactions vary. In fact, some levels of inflammation and even mild soreness are common initially as we are targeting and stimulating your body's healing response. The real magic of this unique therapy is in the long-term effects that accumulate slowly and will not be fully evident until months after your series is complete. This is true healing that takes time unlike the short-term effects of a medication or pill. Even in the best-case scenario, improvement in pain and function can take several months. If you are a few weeks out and are not miraculously better, don't panic. Please be patient, this is not a quick-fix, we are working towards long-term health and vitality. If you are already seeing immediate positive changes, just wait! Keep treating your body well and allow for even more improvement.

Plan to provide a lowered-stress environment to promote optimal healing and results just before and during your series. Exacerbations of emotional stress, overly long hours at work, and sleep deprivation will deplete your body's ability to heal and diminish your results. If you need to shift your series to a more optimal time, or delay your start by a week or two, let us know! We are committed to creating every opportunity for you to get well.

Also, as you are feeling positive effects, do not engage in overly strenuous exercise, outside of your normal activity. Do not plan a competitive athletic event to fall during your series. It is important to provide your body with not only a healing environment but reduced demands to optimize healing. Best results and performance are found about 90 days after your series is complete. If you have questions about a specific activity, ask us and we will consider your unique goals and circumstances.

If you have serious problems with optimal posture, or use improper form for exercise or daily activities, this will put unnecessary stress on your joints and will negatively affect your results. Please talk to us if you need suggestions or guidance.

If you have compromised nerve supply to your treatment area due to a neuro-spinal condition or untreated subluxation this will negatively affect your results. We strongly suggest that you receive any necessary treatment for this condition prior to receiving your Softwave series.

If your treatment doesn't meet your expectations, or you have more questions about how this unique therapy works, Visit https://softwavetrt.com/resear... for additional information.

Acknowledgment Pre-Treatment Guidelines

By signing below you acknowledge your receipt of the Pre-Treatment Guidelines.

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(office use only)

PATIENT INFORMATION

Marital Status*
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Gender*
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What treatment(s) are you interested in? Check all that apply*
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Is this related to an auto accident?*
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PLEASE CIRCLE YOUR AREAS OF CONCERN

Mark your Areas of Concern
Is your condition affecting you at home?*
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Is your condition affecting you at work?*
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Is your condition affecting your energy?*
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Is your condition affecting your mood?*
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Is your condition affecting your hobbies?*
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Is your condition affecting your sleep?*
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Have you been under increased stress in the last year?*
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Have you recently made changes to any medication?*
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Why Chiropractic? People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program.

Please check off the type of care that best meets your needs.

What type of care are you interested in?*
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Check any of the following you have had in the last six months:
Are you pregnant?*
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Method of Payment:*
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I authorize Source Family Chiropractic to render necessary services to me and understand that I am responsible for all charges incurred.

General Questions

Do you have any cancer, tumors, or skin lesions?*
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Are you using a cardiac pacemaker or implantable medical device?*
Please select at least one option

Tissue Regenerative Therapy (TRT)

Have you been injected with cortisone within the last 30 days?*
Please select at least one option
Are you on NSAIDS or anticoagulant treatment?*
Please select at least one option
Do you have a complete tear in the tendon?*
Please select at least one option
Do you have a severe bleeding disorder/tendency?*
Please select at least one option
The 3 TRT benefits will be explained by your doctor.
Risks: The following may occur due to treatment: local discomfort, soreness, bruising, increase in pain. During treatment, patients may experience minimal decrease in sensation, nausea, tingling, headaches, or fainting.

Consent for any of the above modality treatments:

I have read or reviewed the above questions and heard aloud the warnings and contraindications. I have discussed it with the doctor 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 I have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to these treatments. I understand that there are no guarantees as to the success of my individual treatment and that individual treatments may vary from patient to patient.

Image Release

I hereby give permission for Source Family Chiropractic to take photographs and/or videos and/or to record audio for informational and promotional purposes in web content, social media content, social media content, print materials, and any form of media from the first date of my treatment, now and in the future.

I acknowledge that I will not be compensated and that the above-listed entities own the rights to the images, videos, and recordings, and to any derivative works created from them. I waive the right to inspect or approve the uses of any printed or electronic copy and release the above-listed entities from any claims arising from these uses without limitations.

This release expresses the complete understanding of both parties.

Authorization*
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Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

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  • 12200 W Colonial Drive #201,
    Winter Garden, FL 34787

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Business Hours

Monday, Thursday

7:30 am - 6:00 pm

Tuesday, Wednesday

8:30 am - 6:00 pm

Friday

8:30 am - 12:30 pm

Saturday

8:30 am - 10:30 am

Sunday

Closed