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 if there is anything that is unclear.
THE NATURE OF THE CHIROPRACTIC ADJUSTMENT:
The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to 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.
As a part of the analysis, examination and treatment, you are consenting to the following procedures: Spinal manipulative therapy; range of motion testing, orthopedic testing, basic neurological testing, vital signs,postural analysis, Kinesiology (muscle testing), NervExpress heart rate variability testing, allergy sensitivity testing, urine testing, saliva testing, nutritional imbalance testing, physio-therapy including cold laser, PEMF, biofeedback, electrical stimulation, sound wave therapy, moist heat and ice, nutritional and herbal therapy.
THE MATERIAL RISKS INHERENT IN THE CHIROPRACTIC ADJUSTMENT:
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complication include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries of the neck leato or cding ontributing to serious complications including stroke. Some patients will feel 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.
THE PROBABILITY OF THOSE RISKS OCCURRING:
Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during the examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. 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 analgesics and rest; medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers; hospitalization and surgery. If you chose to use one of the above noted "other treatment" options, you should
be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
THE RISKS AND DANGERS ATTENDANT TO REMAINING UNTREATED:
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult
and less effective the longer it is postponed.
BY ELECTRONICALLY SIGNING BELOW I STATE THAT I HAVE WEIGHED THE RISKS INVOLVED IN UNDERGOING TREATMENT AD 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 FOT TREATMENT.