Whole Life Wellness, Llc

ANIMAL CHIROPRACTIC TREATMENT CONSENT
Whole Life Wellness, LLC
Effective Date: 09/22/2026
Last Updated: 09/29/2026

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 that have been discussed with me and deemed appropriate for my animal by the treating provider.

I understand that animal chiropractic care is intended to provide conservative, supportive care for neuromusculoskeletal function and mobility. It is not intended to replace veterinary medical diagnosis, treatment, emergency care, medication, surgery, or other veterinary services when such care is indicated.

Nature and Purpose of Care
The treating provider has explained, or has provided me with the opportunity to discuss, the nature, purpose, expected benefits, and goals of the recommended chiropractic care and supportive therapies. I understand that treatment recommendations may vary based on my animal's condition, examination findings, response to care, and other relevant factors.

I understand that there is no guarantee that my animal will improve as a result of treatment, and no promise or representation has been made regarding a particular outcome or cure.

Potential Risks
I understand that, as with other forms of healthcare, chiropractic care and supportive therapies may involve risks. Depending on my animal's condition and the procedures performed, potential risks may include temporary soreness, stiffness, muscle spasms, tenderness, aggravation or temporary worsening of existing symptoms, or lack of improvement. Although uncommon, more serious complications may occur, including injury to muscles, joints, bones, or other tissues.

I understand that the treating provider cannot anticipate or eliminate every possible risk or complication. I agree to promptly communicate any concerning change 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 medical care. I have the right to seek veterinary evaluation, a second opinion, or other treatment options at any time.

The treating provider may recommend veterinary evaluation or referral when my animal's condition appears to require medical evaluation, diagnostic testing, emergency care, or treatment outside the provider's scope of practice. I understand that I am responsible for obtaining veterinary care when recommended and for seeking emergency veterinary care when appropriate.

Other treatment options may be available depending on my animal's condition, including rest, exercise modification, physical rehabilitation, medications, injections, bracing, diagnostic testing, or surgery. I understand that 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 that have been discussed with me and that are considered appropriate for my animal.

I understand that treatment may be modified or discontinued based on my animal's response, examination findings, safety considerations, or other clinical circumstances. If a substantially different procedure or treatment is recommended, I will have the opportunity to discuss it and provide authorization as appropriate.

No Guarantee of Results
I understand that every animal responds differently to treatment. Chiropractic care may not improve my animal's condition, and improvement cannot be guaranteed.

Acknowledgment and Consent
I have read this consent, or it has been read and explained to me. I have had an opportunity to ask questions and have received satisfactory answers to my questions. I understand the nature and purpose of the proposed care, the potential risks and benefits, and the availability of other treatment options.

I understand the information provided to me and voluntarily consent to chiropractic care and the supportive therapies discussed for my animal.

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

CHIROPRACTIC TREATMENT CONSENT
Whole Life Wellness, LLC
Effective Date: 09/22/2026
Last Updated: 09/29/2026

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.
I understand that the treating chiropractor has explained, or has provided me with the opportunity to discuss, the nature, purpose, expected benefits, and goals of the recommended care. I have had the opportunity to ask questions and have received satisfactory answers to my questions.
Nature and Purpose of Care
I understand that chiropractic care may include spinal or extremity adjustments/manipulation and other supportive therapies that may be recommended based on my history, examination findings, condition, and response to care.
I understand that chiropractic care is not intended to replace appropriate medical diagnosis, treatment, emergency care, medication, surgery, or other healthcare services when those services are indicated.
Potential Risks
I understand that, like other forms of healthcare, chiropractic care and related therapies may involve risks. Potential risks may include temporary soreness, stiffness, tenderness, muscle spasms, bruising, aggravation or temporary worsening of existing symptoms, headache, dizziness, or lack of improvement.
I understand that serious complications are uncommon but may occur. Depending on the type of treatment and my individual health circumstances, these may include injury to muscles, joints, bones, nerves, or other tissues.
I understand that no healthcare provider can anticipate or eliminate every possible risk or complication. I agree to communicate any unusual, worsening, or concerning symptoms to my chiropractor and to 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 have the right to seek medical evaluation, a second opinion, or other treatment options at any time.
The treating chiropractor may recommend evaluation by another healthcare provider when my condition appears to require medical evaluation, diagnostic testing, emergency care, or treatment outside the chiropractor's scope of practice.
Other treatment options may be available depending on my condition, including exercise or activity modification, physical therapy, medications, injections, diagnostic testing, or surgery. I understand that I may discuss these options with my physician or other qualified healthcare provider.
Authorization for Treatment
I authorize the treating chiropractor to provide the chiropractic procedures and supportive therapies that have been discussed with me and that are considered appropriate for my condition.
I understand that treatment may be modified, postponed, or discontinued based on my response to care, examination findings, safety considerations, or other clinical circumstances.
If a substantially different procedure or treatment is recommended, I understand that I will have the opportunity to discuss it and provide consent as appropriate.
No Guarantee of Results
I understand that every person responds differently to chiropractic care. There is no guarantee that treatment will improve my condition, relieve my symptoms, or produce a particular outcome. No promise or representation has been made regarding a specific result or cure.
Acknowledgment and Consent
I have read this consent, or it has been read and explained to me. I have had an opportunity to ask questions about the proposed care, potential risks and benefits, and available alternatives.
I understand the information provided to me and voluntarily consent to chiropractic care and the supportive therapies discussed with me.
This consent applies to my current episode of care and may also apply to future visits when the nature and purpose of the recommended care have been explained to me and I have had an opportunity to ask questions and provide consent.

NOTICE OF PRIVACY PRACTICES
Whole Life Wellness, LLC
Effective Date: 09/22/2026
Last Updated: 09/29/2026

YOUR INFORMATION. YOUR RIGHTS. OUR RESPONSIBILITIES.
This Notice of Privacy Practices describes how Whole Life Wellness, LLC may use and disclose your protected health information (“PHI”), how you can access your health information, and the rights you have regarding your health information.

Please review this Notice carefully.

Whole Life Wellness, LLC is committed to protecting the privacy and security of your health information. We are required by law to maintain the privacy of your protected health information, provide you with this Notice describing our legal duties and privacy practices, and follow the terms of the Notice currently in effect.

YOUR RIGHTS
You have certain rights regarding your health information.

Get a Copy of Your Health Information
You have the right to inspect and obtain a copy of your health information, including medical, clinical, and billing records, in paper or electronic form, as permitted by law.

You may request your records by contacting our Office by using the contact information at the end of this Notice.

We may charge a reasonable, cost-based fee where permitted by law.

Ask Us to Correct Your Health Information
You may request that we correct or amend health information that you believe is inaccurate or incomplete.

We may deny your request in certain circumstances permitted by law. If we deny your request, we will provide you with a written explanation and information about your rights concerning the denial.

Request Confidential Communications
You may ask us to contact you in a particular way or at a particular location.

For example, you may request that we contact you by telephone rather than mail, communicate with you by email, or contact you at a different address.

We will consider reasonable requests and will comply with applicable legal requirements.

Ask Us to Limit What We Use or Share
You may ask us to limit how we use or disclose your health information for treatment, payment, or healthcare operations.

We are not required to agree to every restriction request.

However, if you pay for a healthcare item or service completely out-of-pocket and request that we not disclose information concerning that item or service to your health plan for payment or healthcare operations purposes, we will generally agree to the request unless disclosure is required by law.

Get a List of Those With Whom We Have Shared Information
You have the right to request an accounting of certain disclosures of your health information made during the six years prior to your request.

Certain disclosures are excluded from this accounting, including disclosures for treatment, payment, and healthcare operations and certain other disclosures permitted by law.

Get a Copy of This Notice
You may request a paper copy of this Notice at any time.

You may also request an electronic copy when available.

Choose Someone to Act for You
If you have legally designated an individual to act as your personal representative, that person may exercise your rights and make choices regarding your health information on your behalf, subject to applicable law.

We may require documentation establishing that person's authority to act on your behalf.

File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with Whole Life Wellness, LLC or with 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 HEALTH INFORMATION
We may use or disclose your protected health information without your separate written authorization when permitted or required by applicable law.

Treatment
We may use and disclose your health information to provide, coordinate, or manage your healthcare.

For example, we may use your health information to:
Evaluate your health and condition.
Develop and provide a treatment plan.
Provide chiropractic care and other services offered by Whole Life Wellness.
Coordinate your care with other healthcare providers.
Consult with healthcare professionals involved in your care.
Communicate information necessary for your treatment.

Payment
We may use and disclose your health information to obtain payment for services we provide.

For example, we may provide information to an insurance company, health plan, or other payer when necessary to process or obtain payment for healthcare services.

Healthcare Operations
We may use and disclose your health information for healthcare operations.

Healthcare operations may include:
Quality assessment and improvement.
Staff training.
Auditing and compliance activities.
Business planning.
Credentialing.
Reviewing the performance of healthcare professionals.
Managing and operating our practice.
Maintaining and improving our electronic health-record and scheduling systems.

Appointment Scheduling and Reminders
We may use your contact information and health information as reasonably necessary to schedule and manage appointments.

This may include communications by:
Telephone.
Voicemail.
Text message.
Email.
Postal mail.
Electronic scheduling systems.

We may use an electronic health-record and scheduling platform, such as ChiroApp, to help manage patient records, appointments, communications, and other practice operations.

Required by Law
We may use or disclose your health information when required by federal, state, or local law.

Public Health Activities
We may disclose health information for certain public health activities when permitted or required by law, including reporting certain diseases, injuries, or other public health matters.

Health Oversight
We may disclose health information to government agencies for activities authorized by law, including audits, investigations, inspections, licensing activities, and other healthcare oversight activities.

Legal Proceedings
We may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process when permitted by applicable law.

Law Enforcement
We may disclose health information to law enforcement when permitted or required by applicable law.

Serious Threats to Health or Safety
We may use or disclose health information when necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, consistent with applicable law.

Workers' Compensation
We may disclose health information as authorized by and to the extent necessary to comply with workers' compensation laws and similar programs.

Business Associates and Service Providers
We may disclose protected health information to third-party companies or individuals that perform services on our behalf and require access to protected health information.

These may include companies that provide:
Electronic health-record services.
Appointment scheduling.
Billing and payment services.
Information technology and data storage.
Practice management services.
Electronic communications.
Other services necessary to operate our practice.

When required by law, we require our business associates to appropriately safeguard protected health information and comply with applicable HIPAA requirements.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Certain uses and disclosures of your health information require your written authorization.

Examples may include:
Most uses and disclosures of psychotherapy notes.
Certain uses and disclosures for marketing purposes.
Disclosures that constitute a sale of protected health information.
Other uses and disclosures for which HIPAA requires authorization.
If you provide written authorization, you may revoke that authorization in writing at any time, except to the extent that we have already relied upon the authorization.

MARKETING
We may communicate with you about health-related products, services, or treatment alternatives as permitted by law.

Uses or disclosures of your protected health information for marketing purposes that require your authorization will not be made without obtaining that authorization.

SALE OF HEALTH INFORMATION
We will not sell your protected health information without your written authorization when such authorization is required by law.

COMMUNICATIONS WITH YOU
We may contact you using the contact information you provide to us.

Communications may include appointment reminders, scheduling information, billing information, information about your care, health-related services, or other communications permitted by law.

You may request confidential communications or alternative communication methods by contacting our Office.

Please understand that certain communication methods, including email and text messaging, may involve risks inherent in electronic communication.

YOUR CHOICES
For certain health information, you may have additional choices regarding how we share information.

You may ask us about:
Sharing information with family members or individuals involved in your care.
Sharing information with individuals involved in payment for your care.
Certain disaster-relief situations.
Other uses or disclosures where HIPAA gives you an opportunity to object.

If you have questions about your choices, please contact our Office.

SPECIAL PROTECTION FOR CERTAIN INFORMATION
Certain types of health information may receive additional protection under federal or state law.

For example, certain substance-use-disorder treatment records may be subject to additional federal confidentiality requirements under 42 U.S.C. § 290dd-2 and 42 CFR Part 2.

Where applicable, Whole Life Wellness, LLC will comply with additional privacy requirements that apply to specially protected health information.

OUR RESPONSIBILITIES
Whole Life Wellness, LLC is required by law to:
Maintain the privacy and security of your protected health information.
Provide you with this Notice describing our legal duties and privacy practices.
Follow the terms of the Notice currently in effect.
Notify you as required by law if a breach occurs that compromises the privacy or security of your protected health information.
Provide you with a copy of this Notice upon request.
We reserve the right to change our privacy practices and this Notice.

If we make a material change to our privacy practices, we will make the revised Notice available as required by law, including by posting it on our website and making it available at our office.

The revised Notice will apply to all protected health information we maintain, to the extent permitted by law.

ELECTRONIC HEALTH RECORDS AND ONLINE SERVICES
Whole Life Wellness, LLC uses electronic systems to maintain and manage patient health information and practice operations.

Our electronic systems may be used for:
Maintaining patient health records.
Scheduling appointments.
Managing patient communications.
Processing billing and payments.
Coordinating care.
Managing practice operations.

We take reasonable administrative, technical, and physical safeguards designed to protect the privacy and security of information maintained in these systems.

TEXT MESSAGES, EMAIL, AND ELECTRONIC COMMUNICATION
If you provide your telephone number or email address, we may use that information to communicate with you regarding your healthcare, appointments, billing, scheduling, and other matters permitted by law.

You may request an alternative means of communication if you have concerns about receiving information through a particular method.
Please notify us if your contact information changes.

QUESTIONS OR PRIVACY COMPLAINTS
If you have questions about this Notice, would like to exercise your privacy rights, or believe your privacy rights have been violated, please contact:
Whole Life Wellness, LLC
Address: 1500 Whitehall Rd, Anderson, SC 29625
Phone: 864.314.9715
Email: wholelifewellnesschiro@gmail.com

You may also contact:
U.S. Department of Health and Human Services
Office for Civil Rights

You may file a complaint with the Office for Civil Rights without fear of retaliation.
Information about filing a complaint is available through the U.S. Department of Health and Human Services Office for Civil Rights.

ACKNOWLEDGMENT OF RECEIPT
You may be asked to sign or electronically acknowledge that you received this Notice of Privacy Practices.
Your acknowledgment confirms that you received the Notice. It does not constitute an authorization for uses or disclosures of your health information beyond those permitted by law.

If you decline to sign an acknowledgment, Whole Life Wellness, LLC may document that it made a good-faith effort to obtain your acknowledgment and that the acknowledgment was not obtained.

EFFECTIVE DATE
Effective Date: 09/22/2026
Last Revised: 09/29/2026

Whole Life Wellness, LLC

This Notice of Privacy Practices is provided to meet applicable HIPAA notice requirements. It should be reviewed by qualified healthcare counsel or a HIPAA compliance professional before adoption as the practice's official notice.

FINANCIAL & APPOINTMENT POLICY
Whole Life Wellness, LLC
Effective Date: 09/22/2026
Last Updated: 09/29/2026

Whole Life Wellness, LLC is a private-pay healthcare practice. We do not bill, submit claims to, or accept payment from health insurance companies. Patients are responsible for payment for all services provided by Whole Life Wellness, LLC.

By signing this Financial Policy, you acknowledge that you have read, understand, and agree to the financial policies below.
1. Payment for Services
Payment is due at the time services are provided unless a different arrangement has been approved in advance by Whole Life Wellness, LLC.

Patients are responsible for payment of all services, products, supplements, programs, and other charges incurred.

Our current fees will be communicated to you before services are provided when appropriate.

2. Methods of Payment

Whole Life Wellness, LLC accepts payment methods designated by the practice, which may include:
Credit cards
Debit cards
Cash
Check
Electronic payments

Whole Life Wellness, LLC may require a valid payment method to be maintained on file for applicable charges.

3. Private-Pay Services

Because Whole Life Wellness, LLC does not bill insurance, payment is the patient's responsibility regardless of whether the patient has health insurance.

Patients who wish to seek reimbursement from their insurance company independently are responsible for determining whether their individual plan provides any out-of-network or other reimbursement benefits.

Whole Life Wellness, LLC does not guarantee that an insurance company will reimburse a patient for services received.

4. Appointments, Cancellations, and No-Shows

Appointments are reserved specifically for each patient.

We require at least 24 hours' notice for cancellations or rescheduling.

A cancellation or missed-appointment fee may be charged when:
An appointment is missed without notice;
An appointment is canceled with less than 24 hours' notice; or
A patient repeatedly cancels or reschedules appointments.

The applicable fee will be communicated by Whole Life Wellness, LLC.

Emergencies and unusual circumstances may be considered on a case-by-case basis at the discretion of the practice.

5. Late Arrivals

Please arrive on time for your scheduled appointment.

If you arrive late, your appointment may need to be shortened or rescheduled depending on the circumstances and the provider's availability.

A late arrival does not automatically extend the scheduled appointment time.

6. Outstanding Balances

Payment is expected when due.

If a balance remains unpaid, Whole Life Wellness, LLC may contact the patient regarding the outstanding amount and may require payment of the balance before additional non-emergency services are provided.

Persistently unpaid balances may be referred for collection or otherwise pursued as permitted by applicable law.

7. Returned or Declined Payments
A reasonable fee may be charged for payments that are returned, declined, or reversed, to the extent permitted by applicable law.
The patient remains responsible for the original balance as well as any applicable returned-payment fee.

8. Refunds and Credits
Payments made in error, duplicate payments, or other overpayments may be refunded or applied as a credit toward future services, as appropriate.

Refunds are generally issued to the original payment method when reasonably practicable.

Fees for services already provided are generally non-refundable.

9. Packages, Programs, and Prepaid Services

Certain services may be offered as prepaid packages or programs.

The terms, fees, expiration dates, and applicable cancellation or refund policies for such offerings will be communicated to the patient before purchase.

Unless otherwise stated in writing or required by law, prepaid services are subject to the terms established by Whole Life Wellness, LLC for that particular service or program.

10. Supplements and Products

Payment for supplements, products, equipment, or other retail items is due at the time of purchase.

Returns or exchanges are subject to the applicable product-specific policy.

Opened or used products may not be eligible for return or refund except where required by applicable law.

11. Payment Plans

Payment plans may be offered at the discretion of Whole Life Wellness, LLC.

Any payment plan must be approved by the practice and may require a separate written agreement.

A payment plan does not eliminate the patient's responsibility for the total balance owed.

12. Billing Questions or Disputes

If you believe there is an error in a charge or statement, please contact Whole Life Wellness, LLC as soon as possible so the matter can be reviewed.

Patients remain responsible for undisputed charges while a billing question is being reviewed.

13. Changes to This Policy

Whole Life Wellness, LLC reserves the right to update this Financial Policy as necessary to reflect changes in practice procedures, fees, technology, or applicable law.

Material changes will be communicated as appropriate.

PATIENT ACKNOWLEDGMENT

I acknowledge that:
I have read and understand the Whole Life Wellness, LLC Financial Policy.
I understand that Whole Life Wellness, LLC is a private-pay practice and does not bill or file claims with health insurance.
I understand that I am responsible for payment for all services and products I receive.
I understand the cancellation and missed-appointment policy.
I understand that unpaid balances may be subject to collection efforts as permitted by law.
I have had the opportunity to ask questions regarding this policy.

I have read, understand, and agree to the Whole Life Wellness, LLC Financial Policy. I understand that Whole Life Wellness, LLC is a private-pay practice and that I am responsible for payment for services provided to me.