WELLNESS HEALTH AGREEMENT



ATHLETIC WELLNESS PROGRAM 2019-2020

The purpose of the ATHLETIC WELLNESS PROGRAM is to help athletes maintain peak performance during their event season. Preventative chiropractic care will help maintain spinal integrity during the student’s rigorous athletic season, and, in many cases, keep sports related injuries to a minimum. The ATHLETIC WELLNESS PROGRAM is designed to be convenient and affordable. Wellness/Preventative Care is not covered by insurance plans, yet it can be a vital part of the athlete’s ability to maintain maximum health, prevent a relapse of any prior conditions, and help avoid future health problems associated with sports injuries - saving the athlete and their families both time and money. This agreement outlines the responsibilities and obligation of the doctor and the patient.

DEFINITIONS: Sickness Care is defined as a form of treatment designed to address an obvious injury, symptom, disease, or condition. Wellness Care is recognized as non-symptomatic care designed to maximize optimum spinal and nervous system function and help prevent disease.

ELIGIBILITY: Those qualified for membership must be currently participating in a local athletic program. They must also be non-symptomatic, and have no current injury or related musculoskeletal illnesses, and be recommended by the treating doctor of Chiropractic. A preliminary physical/orthopedic/neurological examination and x-ray (if necessary) will be performed to determine eligibility. NOTE: If the athlete participates in multiple sports programs throughout the year, it will not be necessary to repeat the physical exam or x-ray (unless the athlete has a new injury or illness to report).

INJURY: Members agree to report to the doctor any new or returning health problem, which are not self-limiting and do not resolve in three days. Should injury or sickness care be needed the Athletic Wellness Program is suspended. If the athlete must go under active sickness care, they may use their health insurance for care until wellness is re-established. Benefits can resume when eligibility requirements are met.

TREATMENT STYLE: This agreement entitles patients to one wellness chiropractic adjustment per week. This agreement will be valid for the duration of the sport season in which the athlete is involved. If the athlete participates in more than one sport concurrently or in subsequent programs, they will need to have a coach’s signature for each sport. The patient may receive one therapy treatment if the doctor feels it would be advantageous to their care. No nutritional supplements, outside services, medical supplies, or any other forms of treatment are covered under this agreement.

FEES: The annual fee for an initial examination and x-ray for all athletes entering the 2019-2020 Wellness Program will be $200.00 (The average initial office visit for exam and X-ray at Waupun Chiropractic Center is approximately $300.00 with

average adjustment fees ranging from $58.50 - $75).

In support of ALL Athletic Programs in Waupun and the surrounding area, we will be offering one weekly wellness visit to actively participating athletes for the duration of their athletic season. This agreement expires on July 31, 2020. This fee MUST be paid within 1 week of beginning the program.

EXCLUSIONS: There is no guarantee that any illness, injury, or disease can be prevented or cured by participation in this program. Receipts for income tax purposes can be requested at the end of the year. No insurance filing paperwork will be generated. This plan does not cover any work-related injuries, automobile accidents, personal injury claims, Medicare, Medicaid, or any health condition with a third party financial liability. This agreement may be modified with a 30-day notice.

I have read and understand the terms of this agreement.

PATIENT NAME

____________________________________

PARENT/Guardian Signature

_________________________________________

Date

WAUPUN CHIROPRACTIC CENTER

ATHLETIC WELLNESS PROGRAM

I confirm that ____________________________is participating in ________________for the 2019-2020 athletic season. This season runs from _________________________ to _________________________ (approximately.)

Coach’s Signature_________________________ Date________________________

Athletic Wellness Program 2019-2020

PURPOSE

- Keeps your child in “peak performance”!

- Helps maintain optimum musculoskeletal integrity

- Helps to minimize problems brought on by strenuous athletic activity

THE PROGRAM

- Complete orthopedic/neurological assessment and x-rays if necessary

- All inclusive weekly visit to Waupun Chiropractic Center

Chiropractic Adjustment

Therapy*

Nutritional Counseling*

Peak Performance Education

*Costs of nutritional products or additional orthopedic supports and rental of therapy equipment not included.

Waupun Chiropractic Center, 160 Gateway Dr. Waupun, WI 53963

(920) 324-9899

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