Dr. Nicole Shabino, 3209 Ingersoll Ave. Suite 112, Des Moines IA 50312
We are blessed that you have chosen us to assist you and your family’s health & wellness needs on your journey. Please let us know if there is any
way we can make you and your family more comfortable. We look forward to working with you to build better health for your family.
Patient Name: _____________________________ Preferred Name: ______________
Address: _________________________________ City: ______________________ State: _________ Zip: _______
Birth Date: ____/____/______ Age: _______Sex: ________
How did you hear about mindful journey? __________________________________________
Preferred Phone: ____________________________ Email: _______________________________________
In Case of Emergency Contact: ____________________________Phone #____-_____-______ Relationship: _____________
Have you received chiropractic care before? Y/N If so, what was your experience like? _____________________________________
What brings you to Mindful Journey? Wellness, pregnancy, specific concern, etc.
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Informed Consent & Authorization of Care:
I hereby request and authorize Dr. Shabino to perform any necessary diagnostic tests and render chiropractic adjustments and other needed
treatments. All information on this form is true, what I communicate to the doctor about my health verbally is true, and I will keep the
doctor informed of any changes in my health status or condition. I authorize the doctor to release all information necessary to communicate
with personal physicians and other health care providers. I also understand that all information will be kept confidential within Mindful
Journey, its doctors and agents.
I understand that I am responsible for all costs of chiropractic care, at the time of service, regardless of insurance coverage. I understand that
cancellations of less than 24 hours will be billed at 50%, and appointments missed without notice will be billed at the full fee. The doctors
and agents at Mindful Journey will take health and weather into consideration.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, on me by Dr. Shabino and/or other
licensed doctors of chiropractic who now or in the future work at Mindful Journey, PLLC. I understand it is my responsibility to disclose
pre-existing conditions and will not hold Mindful Journey, its doctors and agents, responsible.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment. I do not expect
the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during
the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I
understand that results are not guaranteed.
I have read the above consent. I understand I have the opportunity to ask questions about its content, and by signing below I agree to the abovenamed procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future
condition(s) for which I seek treatment.
Printed name: ______________________________________________________________________Date:_____________
Signature of Informed Consent & Authorization of Care: ___________________________________________________
DR. NICOLE SHABINO, MINDFUL JOURNEY PLLC
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