Consent To Chiropractic Treatment printable pdf download

CONSENT TO CHIROPRACTIC TREATMENT

It is important for you to consider the benefits, risks and alternatives to the treatments options offered by your

chiropractor and to make an informed decision about proceeding with treatment.

BENEFITS – Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back, and other areas

of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain,

including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and

reduce or eliminate the need for drugs or surgery.

RISKS – The risks associated with chiropractic treatment vary according to each patient’s condition as well as the location

and type of treatment.

The risks include:

 Temporary worsening of symptoms – Usually, any increase in pre-existing symptoms of pain or stiffness will last

only a few hours to a few days.

 Skin irritation or burn – Skin irritation or a burn may occur in association with the use of some types of electrical

or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar.

 Sprain or strain – Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks

with some rest, protection of the area affected and other minor care.

 Rib fracture – While a rib fracture is painful and can limit your activity for a period of time, it will generally heal

on its own over a period of several weeks without further treatment or surgical intervention.

 Injury or aggravation of a disc – Over the course of a lifetime, spinal discs may degenerate or become damaged. A

disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting.

Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they

have a problem with a disc. They also may not know their disc condition is worsening because they only experience

back or neck problems once in a while.

Chiropractic treatment should not damage a disc that is already degenerated or damaged, but if there is a pre-

existing disc condition, chiropractic treatment, like many other common activities my aggravate the disc condition.

The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most

severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the

legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed.

 Stroke – Blood flows to the brain through two sets of arteries passing through the neck. These arteries may

become weakened and damaged, either over time through aging or disease or as a result of injury. A blood clot may

form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can

interrupt blood flow and cause a stroke.

Many common activities of daily living involving ordinary neck movements have been associated with stroke

resulting from damage to an artery in the neck or a clot that already existed in the artery breaking off and traveling

up to the brain.

Chiropractic treatment has been associated with stroke however, that association occurs very infrequently, and may

be explained because and artery was already damaged and the patient was progressing toward a stroke when the

patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic

treatment causes either damage to an artery or stroke.

Consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain

function, as well as paralysis or death.

Alternatives

Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also

prescribe rest without treatment, or exercise with or without treatment.

Questions and Concerns

You are encouraged to ask questions at any rime regarding your assessment and treatment. Bring any concerns you have to

the chiropractor’s attention. If you are not comfortable, you may stop treatment at any time.

PLEASE PREPARE YOUR QUESTIONS FOR THE CHIROPRACTOR AND SIGN THIS FORM AT THAT TIME

I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I

have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to

chiropractic treatment as proposed to me.

___________________________________

Name (Please Print)

____________________________________Date:_______________20____ ____________________________________Date:_______________20_____

Signature of Patient (or legal guardian)

Signature of Chiropractor

Consent To Chiropractic Treatment

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