largechiropracticclinic.com - Informed Consent for Chiropractic Treatment

Informed Consent for Chiropractic Treatment
You have the right to understand your condition, the recommended chiropractic treatment, its purpose, risks, benefits, and alternatives, including no treatment. You may ask questions and may refuse treatment.

I request and consent to chiropractic adjustments and other chiropractic procedures, including adjunctive procedures and diagnostic X-rays when the doctor considers them necessary. Treatment may be provided by a licensed chiropractor at this clinic or a qualified backup/covering doctor.

I understand that chiropractic treatment may involve risks, including broken bones, dislocations, sprains/strains, burns or frostbite from adjunctive procedures, worsening or aggravation of spinal conditions, disc irritation, costovertebral strain/separation, and increased or unchanged symptoms or pain.

Rare complications have been reported with cervical adjustments, including vertebral artery dissection/stroke. Reported complications may include dizziness, nausea, paralysis, vision loss, locked-in syndrome, and death.

I understand that the doctor cannot anticipate every possible risk or complication and that no guarantee or promise has been made regarding results. I have had an opportunity to discuss my care, alternatives, and risks and to have my questions answered.

This consent applies to the course of treatment for my current condition and any future recurrence of a similar condition.
Patient / Representative Signatures
Printed Name of Patient
Printed Name of Representative
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Representative
Signature of Patient
Relationship/Authority
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the patient is a minor or another person is legally authorized to provide consent on the patient’s behalf:
Printed Name of Parent/Legal Guardian/Authorized Representative
Relationship/Authority
I certify that I am legally authorized to consent to healthcare treatment on behalf of this patient, and I consent to the chiropractic examination and treatment described above.
Signature of Parent/Legal Guardian/Authorized Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness, if applicable
Minor Patient Acknowledgment
When appropriate based upon the minor patient’s age and ability to understand the proposed care, the treatment and procedures have been explained to the minor in understandable terms and the minor has been given an opportunity to ask questions.
Minor Patient Signature/Acknowledgment, when appropriate
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The minor’s acknowledgment does not replace the consent of a parent, legal guardian, or other legally authorized person when such consent is required by Pennsylvania law.
AI-Assisted Data Processing Consent
Large Chiropractic Clinic uses AI tools for certain administrative and data-processing functions, which may include organizing, transcribing, summarizing, or otherwise processing information used in connection with your care. These tools support clinic operations and do not replace the professional judgment of your healthcare providers.

I understand and consent to the use of AI tools for these data-processing functions.
Patient Name
Patient or Parent/Legal Guardian/Authorized Representative Signature
Relationship to Patient, if applicable
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Informed Consent for Chiropractic Treatment

Patient / Representative Signatures

Minor Patient Acknowledgment

AI-Assisted Data Processing Consent