Consent For Communication

Recovering from an injury or managing a chronic condition often requires more than just traditional medical care.
Consent For Communication And Treatment
Patient Consent For Communication:

We have the ability to call, text or email you, reminding you of your appointments. If you would like to receive this feature in the future, please read the consent below and sign. Patients may be contacted via phone, text messages to be reminded of an appointment, to obtain feedback on an experience with our office and to provide general health reminders/information. 

1. I consent to receiving appointment reminders and other healthcare communications via telephone and text messages via my cell phone and any number forwarded/ transferred to. The phone number I authorize to receive reminders, feedback and general health information is:

 2. I consent to receiving email communications as stated above. The email I authorize to receive messages for reminders, feedback and general health information is:

IF your appointment is scheduled for a Monday,or a day after a Federal holiday, or after an office closure, we request that you notify our office no later than 6pm the day prior or by noon on Friday to make any changes to your scheduled appointment. 

Same day cancellations / NO SHOWS, there will be a $ 90.00 charge for patients who fail to cancel at least 24 hours in advance, or for patients who fail to show up for their scheduled appointment. Payment is expected on your next scheduled appointment or before.


******Please be advised, this charge IS NOT billable to insurance.********* 


I hereby authorize the Doctor’s/Nurse Practitioner’s of Innerve8 Medical to treat my case as they deem appropriate through the use of lab testing, traction, durable medical equipment, rehabilitation, manual therapy, chiropractic manipulation of the spine, nutritional support, diagnostic testing, procedures and injections, I realize the goal of holistic health care is to strengthen the patient’s body in order to heal themselves. It is understood and agreed the amount paid to the clinic for x-rays is for interpretation and only the x-ray negatives will remain the property of this office, being on file. The patient also agrees he/she is responsible for all bills incurred at this office. 

I understand and agree to the above terms. 

Sign Here
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INNERVE8 MEDICAL, 2034 Eisenhower Avenue Suite 100, Alexandria VA 22314

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