Peak State Chiropractic and Wellness
Consent for Physical Therapy, Chiropractic and Massage Therapy Examination and Treatment
Please read this document carefully and do not sign until you have fully read and understand our policies.
Chiropractic: I understand that the purpose of chiropractic care is to treat disease, injury and disability through the means of examination, evaluations, diagnosis, prognosis and rehabilitative procedures which may include but are not limited to manual adjustments, activator and other modalities.
Physical Therapy: I understand that the purpose of physical therapy is to treat disease, injury and disability through means of examination, evaluation, diagnosis, prognosis and rehabilitative procedures which may include but are not limited to, mobilization, massage, exercise, and other physical agents to aid in achieving the maximum potential within the capabilities.
Massage Therapy: If at any time there are changes in the information given, or in my condition, I will notify the therapist and update the form before receiving additional massage. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive massage.
The massage treatment I am requesting is for the purpose(s) of relaxation, stress reduction, relief from muscle tension or spasm, to improve range of motion, circulation, or energy and to receive a positive experience of touch.
I understand the massage therapist does not diagnose or prescribe medical illness, diseases, or other disorders, and that spinal manipulation are not part of massage therapy. I further understand that massage therapy is not a substitute for medical examination or diagnosis, and that I take responsibility for consulting with my physician of any ailment or condition of concern to me.
Unless in an emergency or inclement weather, I acknowledge that If I am unable to keep a scheduled appointment, 24-hour notice is required or I may be charged for the time reserved.
All therapies: I understand that, as in the practice of medicine, in the practice of other clinical therapies there are some risks in treatment. I understand that if I receive treatments the most common risks are temporary aggravation of my conditions or soreness. Rarer risks include but are not limited to: fractures, strokes, sprains, burns, and aggravations of disc injuries.
I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the procedure which the practitioner feels, based on the facts known then, is in my best interest.
If at any time there are changes in the information given, or in my condition, I will notify the therapist and update the form before receiving additional treatment. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive physical therapy I will communicate this to the therapist.
If I experience any pain or discomfort during any treatment, I will immediately communicate that to the practitioner so that treatment can be adjusted accordingly. I understand that my feedback is an essential element in my treatment If at any time I become uncomfortable during the treatment, I may bring that to the attention and request the session be modified, temporarily suspended, or brought to an end. However, I can ask that a session be discontinued at any time, for any reason, and the practitioner will honor that request.
I have read, or have had read to me, the above consent. By signing below, I agree to the above-named procedures. I intend for this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
*Signature at end of form