I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures to be performed on myself, or the patient named below, for whom I am legally responsible. This includes, but is not limited to examination tests, diagnostic x- rays and physiotherapy techniques which are recommended by Dr. Jeffrey Robichaud who will be rendering treatment to me.

I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. These include, but are not limited to, fractures, dislocations, muscle strains, Horner's Syndrome, diaphragmatic paralysis, cervical myelopathy, costovertebral strains and joint separations. Some forms of cervical manipulation have been associated with injuries to the arteries of the neck leading to or contributing to serious complications- including stroke. This is a very rare occurrence, estimated at 1:3,000,000. We screen our patients for contraindications to cervical manipulation to the best of our ability.

I DO NOT expect Dr. Robichaud to be able to anticipate all the risks and complications. I do expect the Doctor to exercise good judgment during care performing procedures which are in my best interest in both safety and efficacy.

I have read, or have had read to me, the above explanation of chiropractic adjustments and related therapies. By signing below, I am stating I have weighed the risks involved in undergoing treatment and have decided in favor of moving forward with care. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent to cover the entire course of care for my present condition and for future conditions for which I seek treatment.