Consent for Care

Legg Chiropractic and Acupuncture, PLLC
13757 W Bell Rd #101, Surprise, AZ 85374
(623) 214-7600
Effective date: September 13, 2026

Please read this before you sign. It covers your care, what it costs, and your privacy.

In short, here is what you are agreeing to

1. You agree to chiropractic and acupuncture care, and you have read the risks below.
2. You understand that serious problems are rare, and the rare risks are listed below.
3. You may refuse any part of your care at any time.
4. You are responsible for what your plan does not cover, and balances left unpaid after 90 days may accrue interest of no more than 3 percent a year.
5. Our Notice of Privacy Practices is available to you before you sign.

Consent for care

What we may do

Chiropractic adjustment of the spine and extremities, soft tissue work, therapeutic exercise, electrical muscle stimulation, acupuncture, and dry needling. Acupuncture and dry needling are separate procedures with separate Arizona credentials. Dr. Legg is certified in acupuncture by the Arizona State Board of Chiropractic Examiners and is qualified in percutaneous therapy, the Arizona term for dry needling. He performs both himself.

Risks of adjustment

Common: mild soreness, stiffness, or fatigue for days up to weeks. Uncommon: dizziness, headache, or a temporary increase in symptoms. Rare: fracture, disc injury, nerve injury, and, with adjustment of the low back, cauda equina syndrome, which affects bowel and bladder control. Rare: reports of arterial injury in the neck. A causal link to adjustment has not been established.

Risks of acupuncture and dry needling

Common: mild soreness, a small bruise, brief fatigue. Uncommon: bleeding, lightheadedness or fainting, temporary worsening of symptoms. Rare: infection, nerve injury, needle breakage, retained needle, and, with needling near the rib cage, shoulder, or upper back, a punctured lung, which requires emergency care.

X-rays

Recommended when clinically appropriate. They use ionizing radiation, which carries a small risk. Tell us before imaging if you could be pregnant.

Financial interest in imaging

Dr. Legg has a financial interest in the X-ray equipment used at this office. You are free to have any imaging performed at a facility of your own choosing, and your care here does not depend on that choice.

Your alternatives

You may decline care here or refuse any part of it at any time, and you may choose medical evaluation, physical therapy, medication, injection, or surgery instead.

No guarantee

Results vary between individuals. No guarantee of results has been made to me.

Financial policy

You are treated by Dr. Derek M. Legg, D.C., M.P.H. of Legg Chiropractic and Acupuncture. Billing for your care is handled by Sheitelman Physical Medicine, and I authorize assignment of insurance benefits for services rendered to me to Sheitelman Physical Medicine. I am responsible for deductibles, copayments, coinsurance, and services my plan does not cover. Balances unpaid after 90 days may accrue interest at the maximum rate Arizona law allows on medical debt, which is no more than 3 percent a year. If you need time, ask, and we will put a written payment plan in place with no interest. Unused prepaid services are refundable on written request. Visits already completed are charged at the price in effect on the day they were provided and are not repriced afterward. To stop a monthly plan, tell us in writing at least 5 days before your next charge date, and it ends with no further charges.

Direct pay

If we are contracted with your health plan and you choose to pay us directly for a service instead of using that coverage, Arizona law requires a separate written notice and your signature before that service. Ask us and we will give you one.

Good faith estimate

If you are uninsured, or you are not using insurance for a service, federal law gives you the right to a written estimate of what your care is expected to cost. Ask us for one and we will give it to you before your visit.

Privacy

Your protected health information may be used or disclosed for treatment, payment, and health care operations. You have the right to see and copy your record, ask us to amend it, receive an accounting of certain disclosures, request restrictions, ask us to contact you a particular way, receive a paper copy of the notice, be notified of a breach, and complain to us or to the United States Department of Health and Human Services without retaliation. If you pay for a service in full out of pocket, you may require that we not tell your health plan about it, and we must honor that. We may speak with the emergency contact you listed about your care when you do not object, or when you are unable to speak for yourself. Our Notice of Privacy Practices is available to you before you sign, at leggchiropractic.com/privacy-practices. By signing you acknowledge you were given it and had the chance to read it.

Who signs

If the patient is under 18, or cannot sign for themselves, this form must be signed by a parent, a legal guardian, or the person holding health care power of attorney. By signing, that person confirms they hold that authority.

If your care is for a motor vehicle collision or a work injury, different rules apply and you will complete a separate injury intake. You may keep a copy of this form.

Related pages

Our HIPAA Notice of Privacy Practices covers protected health information in full. Our privacy policy covers information collected on this website. What to expect at the office is on the first visit page, coverage questions are on the insurance accepted and Medicare pages, and care after a crash or a work injury is on the auto accident injuries and work injuries pages. To book, use the schedule page or call (623) 214-7600.