The privacy of your medical information, as described in the HIPPA Privacy Act, is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use medical information about you to doctors, nurses, technicians, medical students or other health care providers to assist them in treating you. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

Dixon Chiropractic

Consent to treat: I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, acupuncture, diagnostic x-rays, and any supportive therapies on me ( or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed, working, or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Acupuncture involves inserting tiny, flexible, sterile needles through the skin and into muscles and connective tissues in order to relieve symptoms, resolve pain and muscle tension, increase movement, and promote healing. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.

RISKS: I understand and am informed that, as in the practice of medicine and like all other health modalities, results are not guaranteed, and there is no promise of cure. I further understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, nerves, or spinal cord, strokes, dislocations, and sprains. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare". The most serious risk with acupuncture is accidental puncture of a lung (pneumothorax).  If this were to occur, it may likely require a chest x-ray and no further treatment.  This is a rare complication. Other risks include injury to a blood vessel causing a bruise, infection, nerve injury. and/or vasodepressor syncope (feeling faint.)   If heat or moxa therapy is used, there is the risk of a burn and scaring.  Bruising and temporary pain (12-24 hours) at needle sites are common occurrences and should not be a concern. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and are in my best interests.

Other treatment options which could be considered may include the following:

·        Over-the-counter analgesics: The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.

·        Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.

·        Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.

·        Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition.  My healthcare provider has also discussed with me the probability of success of this procedure(s), as well as the probability of serious side effects.    Multiple treatment sessions may be required, thus this consent will cover this treatment as well as consecutive treatments by this provider and this facility.  I have read and fully understand this consent form and understand that I should not sign this form until all items, including my questions, have been explained or answered to my satisfaction.  With my signature, I hereby consent to the performance of this procedure.  I also consent to any measures necessary to correct complications which may result.

Doctor of Chiropractic: Dr. Ashley Dixon, DC