Consent to care at
Gateway Family Chiropractic
Chiropractic Examinations and X-Rays
The State of Colorado requires every patient to be informed of the risks of treatment and the alternatives to treatments prior to the beginning of care. The following is Gateway Family Chiropractic’s informed consent for treatment. We intend this consent form to cover the entire course of treatment for your present condition and for any conditions for which you seek treatment at this clinic.
I hereby authorize Gateway Family Chiropractic and its licensed doctors and certified chiropractic assistants, based on my complaints and the history I have provided, to undertake an examination and provide an evaluation and treatment plan which may include chiropractic adjustments and other tests and procedures considered therapeutically appropriate. I also wish to rely on the practice doctors to make those decisions about my care, based on the facts then known, that they believe are in my best interest.
The specifics of the doctor’s recommendation will be further explained during a Report of Findings following your examination and any subsequent examinations and significant changes in your diagnosis or treatment plan.
The nature of chiropractic treatment. The doctor will use his/her hands or a mechanical device in order to adjust/manipulate your joints. You may hear a "click" or "pop", similar to when a knuckle is "cracked" and you may feel movement of the joint. Various ancillary procedures, such as a hot or cold packs, percussor massage, traction as well as exercise instruction may also be used. Chiropractic adjustments and supportive treatment is designed to reduce/correct subluxations allowing the body to return to improved health.
Possible risks and probability. There are inherent risks in our and all treatment derived by any health care provider ranging from taking a single aspirin to a complicated brain surgery. Chiropractic care is no exception. Although we take every precaution, there are indeed some slight risks to chiropractic adjustments/manipulations. The risk is very minor to non-existent in any treatment of the extremities. The risks involved in treatment to the spine excluding the neck are several. A list from the least to the most serious would include muscular strain (rare), ligamentous sprain (rare), fractures (rare), and injury to the intervertebral discs, nerves, or spinal cord (very rare). The risk involved in the treatment of the neck would include any of the preceding list but also include the remote possibility of cerebrovascular injury, or stroke (very rare: incident rate is one in ten million). A minority of patients may notice a stiffness or soreness after the first few days of treatment (common). The ancillary physical therapy procedures could produce skin irritations, burns or other minor complications (rare).
Other treatment options, not provided by this clinic, which could be considered, may include the following:
Over-the-counter analgesics. The risks of these medications include irritations to the 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 numerous undesirable effects, usually more serious than those listed above and patient dependence in a significant number of cases.
Surgery in conjunction with medical care adds the risks of adverse reactions to anesthesia (which include death), as well as extended convalescent period in a significant number.
Our services are not provided by medical doctors and are not intended to replace medical care. Our doctors of chiropractic do not prescribe legend drugs or controlled substances and all changes to prescription medications must be made by your prescribing provider. Never stop or change a medication without first talking to your prescribing provider.
Risks of remaining untreated. Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and include chronic pain cycles. It is quite probable the delay of treatment will complicate the condition, and make further rehabilitation more difficult.
Private consultation & recording: You may be seen by a doctor of chiropractic, another licensed provider, or an certified chiropractic assistant who provides services under supervision. You may request a private consultation with the doctor of chiropractic at any time and will be afforded the opportunity for a confidential conversation in a private space. For your saftey and ours and for quality control, our office may use cameras and recording devices to monitor general areas and treatment rooms. You specifically consent to such recordings.
No guarantee – no promise to cure: Results are not guaranteed. Every individual approaches and responds to care differently. No guarantee or assurance is made as to the results or outcome of care, as our services may not improve your condition. Remember, healing and correction take time. Like all other health modalities, results are not guaranteed, but our office sees remarkable results for many of our patients. If at any time you have questions, concerns or confusion, please arrange for a consultation with the doctor immediately - we want you to get the most from your care.
Care plans; cancellations: when a care plan is made, it includes a planned course of action to help achieve the desired results. Missed appointments should be made up as soon as possible. We are committed to provide quality chiropractic care to everyone in our community. In order to help achieve this goal, we request 24-hour notice of cancellation. We understand that life happens and will do all we can to timely reschedule. There will be a $25 cancellation fee if 24 -hour notice of cancellation is not provided.
Massage Therapy: I understand that the massage given to me by massage therapy staff at Gateway Family Chiropractic is for the purpose of stress reduction, pain reduction, relief from muscle tension, to increase circulation, or other specific reasons
I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.
I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.
I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any changes.
Concerns or questions. Please ask your Doctors of Chiropractic or the staff at Gateway Family Chiropractic. They have gone to great lengths to make your health and safety a top priority. The doctors will be glad to explain any concerns about treatment you may have. We will only recommend treatment for you that we would feel comfortable having performed on ourselves.
I have read the above consent. I also had the opportunity to ask questions and have them answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and hereby give my full consent to treatment.