Sensory Checklist

From Raising a Sensory Smart Child, © Biel & Peske, 2005

TOUCHTOUCHTOUCHTOUCHTOUCH

AVOIDS SEEKS MIXED NEUTRAL

Being touched on some body parts, hugs and cuddles ! ! ! !Certain clothing fabrics, seams, tags, waistbands, cuffs, etc. ! ! ! !Clothing, shoes, or accessories that are very tight or very loose ! ! ! !Getting hands, face, or other body parts “messy” with paint, glue, sand, food, lotion, etc. ! ! ! !Grooming activities such as face and hair washing, brushing, cutting, and nail trimming ! ! ! !Taking a bath, shower, or swimming ! ! ! !Getting toweled dry ! ! ! !Trying new foods ! ! ! !Feeling particular food textures and temperatures inside the mouth—mushy, smooth, etc. ! ! ! !Standing close to other people ! ! ! !Walking barefoot ! ! ! !

PROPRIOCEPTION (BODY SENSE)PROPRIOCEPTION (BODY SENSE)PROPRIOCEPTION (BODY SENSE)PROPRIOCEPTION (BODY SENSE)PROPRIOCEPTION (BODY SENSE)

AVOIDS SEEKS MIXED NEUTRAL

Activities such as roughhousing, jumping, banging, pushing, bouncing, climbing, hanging, and other active play ! ! ! !High-risk play (jumps from extreme heights, climbs very high trees, rides bicycle over gravel) ! ! ! !Fine motor tasks such as writing, drawing, closing buttons and snaps, attaching pop beads and snap-together building toys ! ! ! !Activities requiring physical strength and force ! ! ! !Eating crunchy foods (pretzels, dry cereal, etc.) or chewy foods (e.g., meat, caramels) ! ! ! !Smooth, creamy foods (yogurt, cream cheese, pudding) ! ! ! !Having eyes closed or covered ! ! ! !

! 2009, Lindsey Biel, OTR/L

VESTIBULAR (MOVEMENT SENSE)VESTIBULAR (MOVEMENT SENSE)VESTIBULAR (MOVEMENT SENSE)VESTIBULAR (MOVEMENT SENSE)VESTIBULAR (MOVEMENT SENSE)

AVOIDS SEEKS MIXED NEUTRAL

Being moved passively by another person (rocked or twirling by an adult, pushed in a wagon) ! ! ! !Riding equipment that moves through space (swings, teeter-totter, escalators and elevators) ! ! ! !Spinning activities (carousels, spinning toys, spinning aroundin circles) ! ! ! !Activities that require changes in head position (such as bending over sink) or having head upside down (such as somersaults, hanging from feet)

! ! ! !

Challenges to balance such as skating, bicycle riding, skiing, and balance beams ! ! ! !Climbing and descending stairs, slides, and ladders ! ! ! !Being up high, such as at the top of a slide or mountain overlook ! ! ! !Less stable ground surfaces such as deep pile carpet, grass, sand, and snow ! ! ! !Riding in a car or other form of transportation ! ! ! !

AUDITORY/LISTENINGAUDITORY/LISTENINGAUDITORY/LISTENINGAUDITORY/LISTENINGAUDITORY/LISTENING

AVOIDS SEEKS MIXED NEUTRAL

Hearing loud sounds—car horns, sirens, loud music or TV ! ! ! !Being in noisy settings such as a crowded restaurant, party,

or busy store! ! ! !

Watching TV or listening to music at very high or very low

volume ! ! ! !

Speaking or being spoken to amid other sounds or voices! ! ! !

Background noise when concentrating on a task (music,

dishwasher, fan, etc.)! ! ! !

Games with rapid verbal instructions such as Simon Says or

Hokey Pokey ! ! ! !

Back-and-forth, interactive conversations ! ! ! !Unfamiliar sounds, silly voices, foreign language ! ! ! !Singing alone or with others ! ! ! !

! 2009, Lindsey Biel, OTR/L

VISIONVISIONVISIONVISIONVISION

AVOIDS SEEKS MIXED NEUTRAL

Learning to read or reading for more than a few minutes ! ! ! !Looking at shiny, spinning, or moving objects ! ! ! !Activities that require eye-hand coordination such as baseball, catch, stringing beads, writing, and tracing

! ! ! !

Tasks requiring visual analysis like puzzles, mazes, andhidden pictures

! ! ! !

Activities that require discriminating between colors, shapes, and sizes

! ! ! !

Visually “busy” places such as stores and crowded playgrounds ! ! ! !Finding objects such as socks in a drawer or a particular book on a shelf

! ! ! !

Very bright light or sunshine, or being photographed with a flash

! ! ! !

Dim lighting, shade, or the dark ! ! ! !Action-packed, colorful television, movies or computer/video games

! ! ! !

New visual experiences such as looking through a kaleidoscope or colored glass

! ! ! !

TASTE AND SMELLTASTE AND SMELLTASTE AND SMELLTASTE AND SMELLTASTE AND SMELL

Smelling unfamiliar scents AVOIDS SEEKS MIXED NEUTRAL

Strong odors such as perfume, gasoline, cleaning products ! ! ! !Smelling objects that aren’t food such as flowers, plastic items, playdough, and garbage

! ! ! !

Eating new foods ! ! ! !Eating familiar foods ! ! ! !Eating strongly flavored foods (very spicy, salty, bitter, sour, or sweet)

! ! ! !

! 2009, Lindsey Biel, OTR/L

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&&

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.!!!

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.!