Whole Life Wellness, Llc

Whole Life Wellness, LLC

Effective Date: 09/22/2026
Last Updated: 11/02/2026

I am the owner or legally authorized representative of the animal identified on this form. I voluntarily request and consent to animal chiropractic care and any supportive therapies discussed with me and deemed appropriate by the treating provider.

Nature and Purpose of Care
I understand that animal chiropractic care is intended to support neuromusculoskeletal function, mobility, and overall wellness. It does not replace veterinary diagnosis, medical treatment, emergency care, medication, or surgery.

The treating provider has explained, or provided an opportunity to discuss, the recommended care, its purpose, expected benefits, and goals. I understand that treatment recommendations may change based on my animal's condition, examination findings, and response to care. No specific results or cure are guaranteed.

Potential Risks
I understand that chiropractic care and supportive therapies may involve risks, including temporary soreness, stiffness, muscle spasms, tenderness, or temporary worsening of existing symptoms. More serious complications, such as injury to muscles, joints, bones, or other tissues, may occur but are uncommon.

I understand that not all risks can be anticipated or eliminated and agree to promptly report any concerning changes in my animal's condition following treatment.

Veterinary Care and Referral
I understand that animal chiropractic care is complementary to, and does not replace, appropriate veterinary care. I may seek veterinary evaluation, a second opinion, or other treatment options at any time.

The treating provider may recommend veterinary evaluation or referral if my animal requires medical assessment, diagnostic testing, emergency care, or treatment outside the provider's scope of practice. I am responsible for obtaining recommended veterinary care and seeking emergency care when necessary.

Other treatment options may include rest, exercise modification, rehabilitation, medication, diagnostic testing, injections, bracing, or surgery. I may discuss these options with my animal's veterinarian.

Authorization for Treatment
I authorize the treating provider to perform the chiropractic procedures and supportive therapies discussed with me and considered appropriate for my animal.

I understand that treatment may be modified or discontinued based on my animal's response, examination findings, or safety considerations. Any substantially different treatment will be discussed with me, and authorization will be obtained as appropriate.

Acknowledgment and Consent
I acknowledge that I have read and understand this consent, have had the opportunity to ask questions, and have received satisfactory answers. I understand the purpose of care, potential risks and benefits, and available alternatives.

I voluntarily consent to the chiropractic care and supportive therapies discussed for my animal.

This consent applies to the current episode of care and may extend to future visits when the recommended care has been explained and I have had the opportunity to ask questions and provide consent.

Whole Life Wellness, LLC

Effective Date: 09/22/2026
Last Updated: 11/02/2026

I voluntarily request and consent to chiropractic care and supportive therapies provided by the treating chiropractor. I understand that chiropractic care is intended to support musculoskeletal function, mobility, and overall physical well-being.

Nature and Purpose of Care
I understand that chiropractic care may include spinal or extremity adjustments/manipulation and other supportive therapies recommended based on my health history, examination findings, and individual needs.

The treating chiropractor has explained, or provided an opportunity to discuss, the nature, purpose, expected benefits, and goals of care. I have had the opportunity to ask questions and receive satisfactory answers.

I understand that chiropractic care does not replace appropriate medical diagnosis, treatment, emergency care, medication, surgery, or other healthcare services when indicated.

Potential Risks
I understand that chiropractic care and related therapies may involve risks, including temporary soreness, stiffness, tenderness, muscle spasms, bruising, headaches, dizziness, temporary worsening of existing symptoms, or lack of improvement.

Serious complications are uncommon but may include injury to muscles, joints, bones, nerves, or other tissues. I understand that not all risks can be anticipated or eliminated. I agree to report unusual or worsening symptoms to my chiropractor and seek appropriate medical attention when necessary.

Medical Care and Referral
I understand that chiropractic care is complementary to, and does not replace, appropriate medical care. I may seek medical evaluation, a second opinion, or other treatment options at any time.

The treating chiropractor may recommend referral to another healthcare provider if my condition requires medical evaluation, diagnostic testing, emergency care, or treatment outside the chiropractor's scope of practice.

Other treatment options may include activity modification, physical therapy, medications, injections, diagnostic testing, or surgery. I may discuss these options with my physician or another qualified healthcare provider.

Authorization for Treatment
I authorize the treating chiropractor to perform the chiropractic procedures and supportive therapies discussed with me and considered appropriate for my condition.

I understand that treatment may be modified, postponed, or discontinued based on my response, examination findings, or safety considerations. Any substantially different procedure or treatment will be discussed with me, and consent will be obtained as appropriate.

No Guarantee of Results
I understand that everyone responds differently to chiropractic care. No specific improvement, symptom relief, outcome, or cure is guaranteed, and no promise has been made regarding results.

Acknowledgment and Consent
I acknowledge that I have read and understand this consent, or it has been read and explained to me. I have had the opportunity to ask questions and understand the nature of care, potential risks and benefits, and available alternatives.

I voluntarily consent to chiropractic care and the supportive therapies discussed with me.

This consent applies to my current episode of care and may extend to future visits when the nature and purpose of recommended care have been explained and I have had the opportunity to ask questions and provide consent.

Whole Life Wellness, LLC

Effective Date: 09/22/2026
Last Updated: 11/02/2026

YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.
This Notice explains how Whole Life Wellness, LLC may use and disclose your protected health information (PHI), your privacy rights, and our responsibilities for protecting your information.

We are required by law to maintain the privacy of your PHI, provide this Notice, and follow its current terms.

YOUR PRIVACY RIGHTS
You have the following rights regarding your health information:

Access Your Records: Request to inspect or receive paper or electronic copies of your health and billing records. Reasonable, cost-based fees may apply where permitted by law.

Request Corrections: Ask us to correct information you believe is inaccurate or incomplete. We may deny requests as permitted by law and will provide a written explanation if denied.

Request Confidential Communications: Ask us to contact you by a specific method or at a particular address, such as by phone instead of mail. We will accommodate reasonable requests as required by law.

Request Restrictions: Ask us to limit how we use or disclose your information for treatment, payment, or healthcare operations. We are not required to agree to every request. However, if you pay for a service completely out-of-pocket and request that we not disclose related information to your health plan for payment or healthcare operations, we will generally honor that request unless disclosure is required by law.

Request an Accounting of Disclosures: Request a list of certain disclosures of your PHI made during the six years before your request. Disclosures for treatment, payment, healthcare operations, and certain others are excluded.

Obtain a Copy of This Notice: Request a paper or electronic copy at any time.

Choose a Personal Representative: A legally authorized representative may exercise your rights on your behalf, subject to applicable law and verification of their authority.

File a Complaint: You may file a privacy complaint with our office or the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION
We may use or disclose your PHI without separate written authorization when permitted or required by law.

Treatment: To evaluate your condition, develop treatment plans, provide chiropractic care and other services, and coordinate care with other healthcare providers.

Payment: To obtain payment for services provided, including disclosures to health plans or other payers when necessary and permitted by law.

Healthcare Operations: To manage and improve our practice, including quality improvement, staff training, auditing, compliance, business planning, and maintaining electronic health records and scheduling systems.

Appointments and Communications: To schedule appointments and communicate reminders or information through phone calls, voicemail, text messages, email, postal mail, or electronic systems.

Required by Law: To comply with applicable federal, state, or local laws.

Public Health and Oversight: To report certain health matters or cooperate with authorized government agencies, audits, investigations, inspections, and licensing activities.

Legal Proceedings and Law Enforcement: To respond to lawful court orders, subpoenas, administrative requests, or law enforcement requests when permitted or required by law.

Health and Safety: To prevent or lessen a serious and imminent threat to someone's health or safety, consistent with applicable law.

Workers' Compensation: To comply with applicable workers' compensation laws and related programs.

Business Associates and Service Providers: We may share PHI with companies that help operate our practice, including electronic health-record platforms, scheduling services, billing providers, data storage, information technology, and communication services. When required by law, these business associates must safeguard your information and comply with applicable HIPAA requirements.

USES REQUIRING YOUR WRITTEN AUTHORIZATION
Certain uses and disclosures require your written authorization, including most uses of psychotherapy notes, certain marketing activities, the sale of PHI, and other disclosures requiring authorization under HIPAA.

You may revoke an authorization in writing at any time, except to the extent we have already relied upon it.

We will not sell your PHI without your written authorization when required by law.

MARKETING AND COMMUNICATIONS
We may contact you using the phone number, email address, or mailing address you provide regarding appointments, scheduling, billing, healthcare services, and health-related information as permitted by law.

Marketing uses or disclosures requiring authorization will not occur without your written permission.

Email and text messages may involve privacy risks. You may request an alternative communication method or confidential communications by contacting our office. Please notify us if your contact information changes.

YOUR CHOICES
In certain circumstances, you may have the right to agree or object to sharing information with family members, individuals involved in your care or payment, or others as permitted by HIPAA.

Contact our office if you have questions about your choices or applicable restrictions.

SPECIAL PROTECTION FOR CERTAIN INFORMATION

Certain health information may receive additional protection under federal or state law. For example, substance-use-disorder treatment records may be subject to additional confidentiality requirements under 42 U.S.C. § 290dd-2 and 42 CFR Part 2. We will follow additional requirements when applicable.

OUR RESPONSIBILITIES

Whole Life Wellness, LLC is required by law to:

- Protect the privacy and security of your PHI.
- Provide this Notice explaining our privacy practices.
- Follow the terms of the Notice currently in effect.
- Notify you as required by law if a breach compromises the privacy or security of your information.
- Provide a copy of this Notice upon request.

We may update this Notice and our privacy practices. Material changes will be made available as required by law, including through our office and website, when applicable. Revised notices apply to information we maintain as permitted by law.

ELECTRONIC HEALTH RECORDS AND ONLINE SERVICES
We use electronic systems, including ChiroApp, to maintain patient records, schedule appointments, manage communications, process billing, coordinate care, and support practice operations.

We use reasonable administrative, technical, and physical safeguards designed to protect information maintained in these systems.

QUESTIONS OR PRIVACY COMPLAINTS
For questions about this Notice, to exercise your privacy rights, or to file a complaint, contact:

Whole Life Wellness, LLC
1500 Whitehall Rd
Anderson, SC 29625
Phone: 864.314.9715
Email: wholelifewellnesschiro@gmail.com

You may also file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights

You may file a complaint without fear of retaliation.

ACKNOWLEDGMENT OF RECEIPT
You may be asked to sign or electronically acknowledge receipt of this Notice. Your acknowledgment confirms receipt only; it does not authorize uses or disclosures beyond those permitted by law.

If you decline to sign, we may document our good-faith effort to obtain acknowledgment and that it was not obtained.

Whole Life Wellness, LLC

Effective Date: 09/22/2026
Last Updated: 11/02/2026

Whole Life Wellness, LLC is a private-pay healthcare practice. We do not accept insurance, bill insurance companies, or submit insurance claims. Patients are responsible for payment of all services and products received.

By signing this policy, you acknowledge that you have read, understand, and agree to the following terms.

1. Payment for Services
Payment is due at the time services are provided unless another arrangement has been approved in advance. Patients are responsible for all charges for services, products, supplements, and programs. Current fees will be communicated before services are provided when appropriate.

2. Accepted Payment Methods
We accept payment methods designated by the practice, which may include credit cards, debit cards, cash, checks, and electronic payments. A valid payment method may be required to remain on file for applicable charges.

3. Private-Pay Services
Patients are responsible for payment regardless of insurance coverage. If you wish to seek reimbursement independently, you are responsible for determining whether your insurance plan offers reimbursement. Whole Life Wellness does not guarantee reimbursement.

4. Appointments, Cancellations, and No-Shows
Appointments are reserved specifically for each patient. At least 24 hours' notice is required for cancellations or rescheduling.

A cancellation or missed-appointment fee may apply for:
- Missed appointments without notice.
- Cancellations or rescheduling with less than 24 hours' notice.
- Repeated cancellations or rescheduling.

Applicable fees will be communicated by the practice. Emergencies and unusual circumstances may be considered at the practice's discretion.

5. Late Arrivals
Please arrive on time. Late arrivals may result in a shortened appointment or rescheduling, depending on provider availability. Late arrival does not extend the scheduled appointment time.

6. Outstanding Balances
Payment is expected when due. A $25.00 late fee will automatically be applied to balances unpaid after 7 days. Unpaid balances may require payment before additional non-emergency services are provided and may be referred for collection as permitted by law.

7. Returned or Declined Payments
A $35.00 fee will be added to the invoice for returned payments or chargebacks, including insufficient funds (NSF), stopped payments, or failed electronic transactions. Patients remain responsible for the original balance and applicable fees.

8. Refunds and Credits
Duplicate payments, overpayments, or payments made in error may be refunded or credited as appropriate. Refunds are generally issued to the original payment method when practicable. Fees for services already provided are generally non-refundable.

9. Packages, Programs, and Prepaid Services
Fees, expiration dates, and applicable cancellation or refund terms for prepaid packages and programs will be communicated before purchase. Additional terms may apply as established by the practice and applicable law.

10. Supplements and Products
Payment for supplements, products, equipment, and retail items is due at purchase. Returns and exchanges are subject to applicable product policies. Opened or used products may not be eligible for refunds unless required by law.

11. Payment Plans
Payment plans may be offered at the discretion of Whole Life Wellness, LLC and may require a separate written agreement. Patients remain responsible for the full balance owed.

12. Billing Questions or Disputes
Please contact our office promptly if you believe a charge or statement contains an error. Patients remain responsible for undisputed charges while a billing concern is being reviewed.

13. Changes to This Policy
Whole Life Wellness, LLC reserves the right to update this policy to reflect changes in fees, procedures, technology, or applicable law. Material changes will be communicated as appropriate.

PATIENT ACKNOWLEDGMENT
By signing below, I acknowledge that:

- I have read and understand this Financial & Appointment Policy.
- I understand that Whole Life Wellness, LLC is a private-pay practice and does not accept insurance or submit insurance claims.
- I am responsible for payment of all services and products received.
- I understand the cancellation, rescheduling, and missed-appointment requirements.
- I understand the late-payment and returned-payment fees.
- I understand that unpaid balances may be referred for collection as permitted by law.
- I have had the opportunity to ask questions about this policy.

I voluntarily agree to the terms of the Whole Life Wellness, LLC Financial & Appointment Policy.

If your vet would prefer to start the referral process by phone, please contact 864.318.9715 with information requested on this referral form.

Referring Veterinarian Name:
Clinic Name:
Clinic Phone Number:
Clinic Email:
Animal Owner's First Name:
Animal Owner's Last Name:
Animal Owner's Phone Number:
Animal Owner's Email:
Name/Species/Age of Animal Being Referred:
Reason for Referral and Specific Considerations:

Please send all relevant medical records and radiographs with patient referral.