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1. I have had the opportunity to discuss the proposed care with Dr John Surie. I also acknowledge that I have had the opportunity to ask questions about the nature, extent and purpose of the proposed chiropractic care and that I have been given sufficient time to make a decision giving consent for the care to proceed.
   
   
2. I acknowledge that I am aware of and understand the potential risks. I appreciate that results are not guaranteed.
   
   
3. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.
   
   
4. I hereby acknowledge my consent to the performance of the proposed chiropractic care by Dr John Surie and/or any other chiropractor working in this clinic. I understand that I can withdraw consent at any time.
   
   
5. I give this clinic permission to use my postal address to send me birthday cards and thank you cards. I also give permission for my photographs to displayed in this clinic and / or online for the purposes of social sharing and education.
   
   
6. In very rare circumstances, some treatments of the neck may damage a blood vessel and lead to stroke or related symptoms (current statistics eg between 1 in 2 million to 1 in 5.85 million -Haldeman, et al. Spine vol 24-8 1999). Other possible risks include strain/injury to a ligament or a disc in the neck (current statistics eg less than 1 in 139,000) and the low back (current statistics eg 1 in 62,000 Dvorak study in Principles & Practice of Chiropractic, Haldeman 2nd Ed.). For some patients especially with bone weakening diseases, a fracture of a bone although rare is possible.”
   
   
7. I acknowledge that I have discussed with Dr John Surie the rare risks associated with my proposed care which include but are not limited to muscle and joint soreness or strains, nausea and dizziness, fractures, disc injuries including disc encroachments/ruptures, causing nerve irritation and referred symptoms, strokes (or like episodes) and an exacerbation and/or aggravation of my underlying condition. Such risks may result in outcomes such as referral, further tests, surgery, incapacity and the like.35591

Dr John Surie

Doctor of Chiropractic

Provider Number: 5035591H