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: _______________________________________
Parent’s names: ___________________________________________________________________________
In Case of Emergency Contact: ____________________________Phone #____-_____-______ Relationship: _____________
What brings you to Mindful Journey? Wellness, immune boost, specific concern, etc.
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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Informed Consent & Authorization to Administer Care to a Minor:
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 child’s health verbally is true, and I will keep
the doctor informed of any changes in his/her 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.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms
and conditions of my divorce, separation or other legal authorization, the consent of a spouse/ former spouse or other parent is not required.
If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, on my child (or on the patient
named below, for whom I am legally responsible) 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 child’s 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 child’s present condition and for any future
condition(s) for which my child seeks treatment.
Printed name of Guardian: _________________________________Printed name of Minor: _______________________
Guardian Signature of Authorizing Care & Informed Consent: ______________________________Date: ___________
DR. NICOLE SHABINO, MINDFUL JOURNEY PLLC
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