Informed Consent Document
To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.
The nature of the chiropractic adjustment
The primary treatment we use as a Doctor of Chiropractic is spinal manipulative therapy (SMT, CMT). We will use this procedure to treat you. We may use our hands or a mechanical instrument upon your body in such a way as you move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.
Analysis/Examination/Treatment
As part of the analysis, examination, and treatment, you are consenting to the following procedures:
--Stretching
--Chiropractic adjustments
--massage therapy
--exercise rehabilitation
--Microcurrent
--low level laser therapy
—Peripheral nerve stimulators
--Functional medicine/supplements
—non surgical spinal decompression
--pulsed electromagnetic field therapy
--compression therapy
--Vagal nerve stimulattion
--decompression therapy
--traction therapy
--vibration therapy and pulse wave therapy
--red light therapy
--EWOT exercise with oxygen therapy
--Other____________
The material risks inherent in chiropractic care
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and physiotherapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strains, ligament sprains, cervical myelopathy, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke (CVA). Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. Cauda Equina Syndrome has been reported in rare cases which requires immediate medical care.
The probability of those risks occurring
Statistically, Chiropractic Care has been demonstrated to be one of the safest of all healthcare practices. Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the raking of your history and examination. CVA has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur one in five million cervical adjustments. Two major studies (2008, 2015) showed there was not causation between CMT and CVA but rather the patient was already presenting with arterial dissection. The other complications are also generally described as rare.
The availability and nature of other treatment options
Other treatment options for your condition may include:
-Self-administered, over-the-counter (OTC) analgesics, ice, head or rest.
-Medical care and prescription drugs such as anti-inflammatories, muscle relaxants and pain killers. -Hospitalization/Surgery
If you choose to use on of the above noted “other treatment” options, you should be aware that there are severe risks associated with these treatments. Many patients taking OTC NSAID’s such as Ibuprofen and Acetaminophen are not aware that every year there are thousands of deaths associated with their use. No medicine should ever be taken without discussing their side effects and inherent statistical danger with their primary care physician or pharmacist. The PDR is also a good reference regarding pharmaceutical use.
The risks and dangers attendant to remaining untreated
Remaining untreated may create adhesions or scar tissue that can weaken the area and reduce mobility. Further joint degeneration may occur as well as the development of chronic pain syndromes. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.
Media Release:
Video recording takes place on a regular basis. We use footage to help increase awareness that help is available for conditions we see..
This statement authorizes Desert Brain and Spine permission to use my name, likeness and/or voice in any and all of its publications, including website entries, social media, or other without payment or any other consideration. I am aware that I may be asked a variety of questions and that the contents of the interview/testimonial may be published or aired for public view. Should there be questions that make me uncomfortable, I reserve the right to refuse to answer said questions or participate in discussions, and additionally reserve the right to terminate the interview, photo or video session at anytime. I understand and agree that materials produced will become the property of Desert Brain and Spine and will not be returned. I hereby irrevocably authorize Desert Brain and Spine to edit, alter, copy, exhibit, publish or distribute any video, interview or photograph for purposes of publicizing Desert Brain and Spine programs or for any other lawful purposes. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the media. I hereby hold harmless, release and forever discharge Desert Brain and Spine from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of this clinic have or may have by reason of this authorization.
I hereby certify that I am competent to contract in my own name. I have read this release before signing and I fully understand the contents, meaning, and impact of this release.
Cancellation:
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the therapists' day that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment.
No-show or late cancellation appointments are subject to a $50 appointment fee. "Late cancellation" is failure to notify our office by the end of the prior business day. "No show" is failing to appear for your scheduled appointment time. This fee will automatically bill to your ledger and/or credit card on file.
Initial Evaluation Financial Notice- we require a $350 deposit in order to secure your Initial Evaluation appointment time. This is a non-refundable deposit.