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
I, hereby request and consent to the performance of any services provided to me whether by a licensed chiropractor, acupuncturist, massage therapist, physical therapist, chiropractic assistant or any other licensed instructor on behalf of my care to conduct treatments that consist of various forms of adjustments or procedures, including but not limited to various modes of physiotherapy, physical therapy, massage therapy, manual therapy, spinal decompression therapy, radial pressure pulse, cupping, ems training, body ems slimming, class IV laser therapy and diagnostic imaging on me (or on the patient named below, for whom I am legally responsible) by the recommended of either chiropractic, acupuncturist, massage therapist, chiropractic assistant, physical therapist or any other licensed physician or practitioner whom now or in the future will treat me while employed by working, associated with or serving as backup for the doctor(s) of desired treatment, including those working at the office.
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 joint, and improving neurological functioning and overall well-being.
I have had the opportunity to discuss with the treating provider(s) or with other office personnel regarding the nature and purpose of my treatment(s) and or any other procedures. Please understand during any time of your treatment(s) there maybe examinations or tests conducted that will be carefully performed but may cause some discomfort.
Please understand 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, 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, chiropractic adjustment does not cause a dissection in a normal, healthy artery.
The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.
I understand that results are not guaranteed and there is no promise to cure. 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 understand and intend this consent to cover the entire course of care from all providers in this office for my present and for any future condition(s) for of chiropractic, acupuncture, massage therapy or any other service provided to me that there are some risks in treatment, including, but not limited to fractures, dislocations, strokes and sprains. I do not need or expect the doctor or treating physician to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the procedure which the doctor feels at the time, based upon the then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intended this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I may seek treatment.