Informed Consent

Informed Consent to Examination & Treatment

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the Care.

We may conduct some diagnostic or examination procedures, if indicated. Any examinations or tests conducted will be carefully performed, but may be uncomfortable.

Purpose of Chiropractic Care. Chiropractic care centrally involves what is known as a chiropractic adjustment to correct underlying joint dysfunctions (subluxations) to restore proper function of the nervous system and musculoskeletal system.

Nature of Chiropractic Procedures. Chiropractic treatment may include but is not limited to: Spinal and extremity adjustments (manipulation or mobilization), Soft tissue therapies (manual therapy, stretching, cupping, scraping, massage, etc.), Supportive modalities (electrical stimulation, taping, ultrasound, heat/ice, etc.), Exercise and rehabilitation recommendations, and Lifestyle, Ergonomic, or Nutritional advice.

Benefits of Chiropractic Care. Chiropractic adjustments have been shown to effectively reduce muscle, joint, and nerve related pain, improve your posture, restore normal joint motion, enhance nervous system function, and allow your body to heal naturally.

Risks and Possible Side Effects. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: temporary soreness, stiffness, or mild discomfort, muscle strain, joint sprain, muscle spasms, aggravating and/or temporary increase in symptoms, rare complications such as fracture, disc injury, or nerve injury, and extremely rare events such as stroke associated with neck adjustments.

With respect to strokes, this occurs in 3-4 of every 100,000 people, whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

Alternative to Care. Alternatives to Chiropractic care may include: self-administered care, over-the-counter pain relievers, Medical evaluation and treatment (medications, injections, or surgery), Physical therapy or other rehabilitative care, or no care. You are fee to seek or combine any of these options as you choose.

Patient Rights

• I may withdraw consent and discontinue treatment at any time.

• I have the right to ask questions about my diagnosis, recommended care, and alternatives.

• I have the right to a second opinion and to secure other opinions about my circumstances and health care as I see fit.

Consent To Examination & Treatment. I hereby request and consent to chiropractic care and treatment as deemed appropriate by my chiropractor. This consent applies to all providers and staff working at this clinic.

I have had the opportunity to ask questions and all my concerns have been addressed to my satisfaction. I understand the risks and benefits of chiropractic care and wish to proceed.

By signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.