Informed Consent to Care
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.
Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joints, and improving neurological functioning and overall well-being.
It is important that you understand that, 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: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation, and from hot or cold therapies, including but not limited to hot packs and ice, as well as fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains.
With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.
Arterial dissections occur 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.
The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related to between one in one million to one in two million cervical adjustments. By comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract is 1,219 events / per one million persons/year, and the risk of death has been estimated as 104 per one million users.
It is also important that you understand that there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.
For the purposes of our practice, and for this consent form, we adhere to the following definitions:
Health: a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
Vertebral Subluxation: a misalignment of one or more of the 24 movable vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
We do not offer the diagnosis of or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination we encounter non-chiropractic findings, we will advise you appropriately. If you desire advice, diagnosis, or treatment for those findings we will recommend that you seek the services of a health care provider who specializes in the area concerned.
Regardless of what the other disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice is to eliminate a major interference to the expression of the body’s innate wisdom.
Should any insurance or 3rd party payor be involved, I authorize the staff at New Life Chiropractic, P.C. to perform any necessary services needed during diagnosis (of subluxation) and treatment. I also authorize the provider and/or managed care organization to release any information required to process insurance claims (such as those involved in an automobile-related injury).
I understand the above information and the guarantee of this form was completed correctly to the best of my knowledge, and I understand it is my responsibility to inform this office of any changes to my health/medical status.
I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.
The fee paid for the treatment of any x-rays is for analysis only. The x-ray images themselves are the property of this office. Once x-ray images are used for treatment purposes, they cannot be released. Copies can be made if necessary, at the patient’s expense. X-rays, when taken, will be reviewed at the patient’s Report of Findings appointment.
Our policy requires payment in full for all services rendered at the time of the visit unless other arrangements have been made before services are rendered. If your account is not paid within 30 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in the collection process, including a $35 administration fee.
I acknowledge that my information is private and confidential, however, I also acknowledge and approve any necessary correspondences with various third parties, including my GP, specialist, and/or insurance company.
New Life Chiropractic Center provides an appointment reminder service by email, SMS, or phone call. We may also communicate with you by SMS and email from time to time, for the purposes of clinic announcements and patient education.
I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and 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.
New Life Chiropractic conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. By signing below, you acknowledge that you have been made aware of its availability.