Medical doctors, Chiropractic doctors, Osteopaths, Occupational Therapists and Physical Therapists that perform manipulation are required to obtain your informed consent before starting treatment.
I, * do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy, traction, ultrasound, hot packs, Tens unit, exercises, and other
therapeutic modalities may also be used. Although spinal manipulation/ adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows:
Soreness: I am aware that, like exercise, it is common to experience muscle soreness in the first few treatments.
Fractures/ Joint injury: I further understand that an isolated cases underlying physical deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency in our world, stroke from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke to reported to occur once in one million to once in ten million treatments.
Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase of pain and possible blistering. This should be reported to the doctor. Tests have been performed on me to minimize the risk of complications from treatment, and I
freely assume these risks.
I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.
ALTERNATIVE TREATMENTS AVAILABLE
Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over-the-counter medications, exercise and possible surgery.
Consent to evaluate and treatment of a minor child: (if applicable)
I, being the parent or legal guardian of have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care and/or physical therapy.
I have read or have had read to me the above explanation of chiropractic treatment. Any questions I had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.