At Trinity Integrated Medical, we aim to provide the highest quality physical medicine and rehabilitation care. I hereby request and consent to the performance of chiropractic manipulation and manual therapy techniques, including various modes of physical therapeutic modalities and procedures and diagnostic x-rays, where warranted, on me (or on the patient named below, for whom I am legally respoonsible) by the doctors who now of in the future work at Trinity Integrated Medical.
The risks include (but are not limited to) the following:
Chiropractic Manipulation: increased pain or discomfort, fractures, disc injuries, strokes, dislocations, and sprain/strain injuries.
Therapeutic Modalities and Procedures: additional pain and discomfort. Endurance exercises may cause increased risk of acute Myocardial Infarction (heart attack) in patients with known or possible cardiac conditions.
Radiographs: ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.
I acknowledge that I have been informed of the risks involved and understand that if at any time I have concerns they can be discussed with the chiropractor. I appreciate that I will receive the best care possible at Trinity Integrated Medical but that results cannot be guaranteed. I consent to a professional and complete orthopedic examination and to any radiographic examination that the doctor(s) deem as necessary. I understand that any fee for service rendered is due at the time of service.
I do not expect the doctor(s) to be able to anticipate and explain all risks and complications, and I wish to rely upon them to exercise judgment during the procedure which the doctors feel at this time, based upon the facts then known by him or her, is in the best interest.
I understand that my information is private and confidential, however there may be a need to correspond with various third parties, including my primary care provider, specialist or insurance company.
Trinity Integrated Medical provides an appointment reminder service by email or text message and may also communicate with you by SMS and email from time to time, for the purposes of clinic announcements and patient education.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about this consent, and by signing below I agreee to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any condition(s) for which I seek treatment.