Initial Visit

BIRMINGHAM SPORT + SPINE

To provide a more streamlined and efficient patient experience, many aspects of our office communication and paperwork process are handled digitally. Please complete all intake forms prior to your appointment and feel free to text our office anytime at 248-508-0778 with questions or concerns. Our providers personally review all patient information before your visit to ensure a smooth and personalized experience.
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Date of Birth
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Home Phone
(000) 000-0000Format: (000) 000-0000.
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CONSENT TO TREATMENT
Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and benefits of the treatment, and any alternatives to the treatment.
There are some risks that may be associated with treatment, in particular you should note:
a. While rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following treatment.
b. There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal or soft tissue manipulation or treatment.
c. There have been reported cases of injury to a vertebral artery following osseous spinal manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with serious neurological impairment, and may, on rare occasion, result in paralysis or death. The possibility of such injuries resulting from cervical spinal manipulation is extremely rare.
Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions including general pain and loss of mobility, headaches and other related symptoms. The Journal of the American Medical Association recommends using non-invasive treatments for acute low back pain first, including chiropractic care. Musculoskeletal care contributes to your overall well-being. The risk of injuries or complications from treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.
I acknowledge I understand the following:
a. The condition that the treatment is to address;
b. The nature of the treatment;
c. The risks and benefits of that treatment; and
d. Any alternatives to that treatment.
I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and soft tissue manipulation. I intent this consent to apply to all my present and future care with Birmingham Sport and Spine.
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Been hospitalized in the last 5 years?
Had any mental disorders?
Had any broken bones?
Had any strains or sprains?

CONSENT TO TREATMENT