Athletic Wellness Program
The purpose of the ATHLETIC WELLNESS PROGRAM is to help athletes in Osceola County School programs to maintain peak performance during their event season. Preventative chiropractic care will help maintain joint integrity during the student's rigorous athletic season, and, in many cases, keep sport related injuries to a minimum. Dr. McNichols designed a program especially benefiting Osceola County "eligible" student athletes while in season. The benefits of the Athletic Wellness Program includes: physicals, regular chiropractic maintenance, side line attention at home games and practice, sport injury prevention education and health and nutrition advice. This agreement outlines the responsibilities and obligation of the doctor and the patient.
ELIGIBILITY: Those qualified for membership must be Osceola County student athletes in season all grades up through High School. The symptoms, if any, must be related to their sport. A preliminary physical/orthopedic/neurological examination and x-ray (if necessary) will be
performed.
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).
RE-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 for any other reason than sport related, the Athletic Wellness Program is suspended. If the athlete must go under active sickness/injury care for reasons other than sport related, they may use their health insurance for care until the condition is resolved. Benefits can resume when eligibility requirements are met.
TREATMENT STYLE: This agreement entitles patients to one wellness chiropractic adjustment per week, or as deemed clinically necessary by Dr.
McNichols. This agreement may be terminated at anytime by the doctor. If the athlete participates in more than one sport concurrently, they will not need to have multiple agreements. No nutritional supplements, outside services, medical supplies, or any other forms of treatment outside of those listed above are covered under this agreement.
FEES DURING THE CURRENT SEASON: Treatment is complimentary. There are no fees.
FEES AFTER THE CURRENT SEASON: Student athletes may continue are after the season. Contact the East Lake Chiropractic and Medical Center office regarding fees, insurance coverage and forms.
EXCLUSIONS: There is no guarantee that any illness, injury, or disease can be prevented or cured by participation in this program. Receipts
will not be given on each visit. No insurance filing paperwork will be generated. This plan does not cover any injury off-the-field, such as
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 at any time by the doctor.
I have read and understand the terms of this agreement.
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ATHLETE NAME SIGNATURE
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PATIENT OR PARENT/GUARDIAN (UNDER18) SIGNATURE
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DATE
