Chiropractic Intake Form

CANCELLATION POLICY
If you need to reschedule or cancel your appointment we ask that you give us as much notice as possible, ideally 24 hours. If no notice is given the below policy is implemented

1. First time occurrence – A kind reminder of our policy will be given

2. Second time occurrence – Good quality dark chocolate or a bottle of win (no cask wine please)

3. Third time occurrence – A $25 missed appointment fee will be applied.

Please sign below to acknowledge our cancellation policy
Signature

Clear
Date *

Month Day Year
Date
Imaging
Have you had recent imaging at Alto Imaging or Hunter Imaging? *

Yes No
If yes, Do you give permission for Bayside to access your recent imaging reports on your behalf

Yes No
Consent Form for Chiropractic Care

We require all patients to acknowledge their understanding of potential risks, however small, associated with chiropractic care.

Any Health Care intervention attracts some risk, and the chiropractic profession is proud of the safe track record we have maintained over more than 100 years of service.

We have listed some significant risks below with a comparison to some common medical risks to put the issue into some perspective

Chiropractic Care		Medical/Other
Temporary discomfort after Chiropractic adjustment	1/50 (estimate)	Stomach bleedings from anti-inflammatories after 1 month	1/250
Lumbar disk injury	1/62,000	Death from anti-inflammatories	360/year
Cervical neck injury	1/139,000	Death from general anesthetic	1/1,250
Lumbar nerve injury	1/188,000	Injury from car accident	1/9,300
Loss of consciousness and spinal cord damage	1/382,000	Death from lightning strike	1/20,000
Death from stroke	1/5.8 million

As you can see chiropractic involves very safe procedures. Once you understand the risk involved and are happy to continue to recieve chiropractic care please complete the consent form below.

If you have any concerns, Sean is happy to discuss this further with you.

Name of Patient *
Date *

Month Day Year
Date
Signature

Clear
Signature of Parent or Guardian

Clear
Dr Sean Mahony, Chiropractor

--------------------------------
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

	0 - No Pain	1 - Mild Pain	2- Moderate Pain	3- Severe Pain	4 - Worst Possible Pain
Pain Intensity
Sleeping
Personal Care (washing, dressing etc)
Travel
Work
Recreation
Frequency of pain
Lifting
Walking
Standing

Functional Rating Index

CANCELLATION POLICY

Imaging

Consent Form for Chiropractic Care