Confidential Patient Information (Page 3 of 3) in pdf

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

We use a multitude of techniques and tailor the care of our patients and practice members to their individual

needs and limitations. We take great care to maximize results while minimizing risks. However, as in all forms

of care and treatment, some risk is inevitable and unavoidable. In chiropractic care in general, some of the

associated risks are listed below:

o As we seek to make changes in the way your body works, sometimes patients may experience a

short term aggravation of their symptoms, muscle strains, or ligament sprains. If you have

symptoms, they may get worse before they get better.

o While it has never occurred in our office, rib fractures have been reported as a result of manual

adjustment of the midback. For patients with increased risk (osteoporosis, etc), we will alter the

way in which we adjust these areas in order to minimize that risk.

o There are reported cases of cerebrovascular incidents or stroke that have been associated with

many common neck movements, including painting a ceiling, backing up a car, having your hair

washed at a salon, and manipulation of the cervical spine. The most up to date research does not

show a causal relationship between chiropractic adjustment and stroke. We are, however,

required to inform you of these reports. Strokes have potentially serious neurological

impairments, and possible paralysis, no matter the cause. The possibility of such injury to

happen after a visit to a chiropractic office has been shown to be the same as a visit to a medical

office, and is extremely remote. No reputable study has shown that a stroke was caused by a

chiropractic adjustment. We screen each patient for risk factors of stroke and modify our

treatments to reduce risk of any sort.

o Rarely, there are reported cases associating an injury to the intervertebral disc following cervical

and lumbar adjustments, although these cases also have not been supported by the demonstration

of causal relationship. We take care to screen each patient to determine which adjustment

techniques would best suit them to achieve maximum benefit with minimized risk.

Chiropractic treatment and chiropractic adjustments have been the subject of many government reports and

interdisciplinary studies conducted over the last 115 years, and have been demonstrated to be safe and effective.

Chiropractic care contributes to your overall well being, and the risks of injuries or complications from

chiropractic treatments is substantially lower than many other forms of treatment.

I acknowledge that I have had the opportunity to discuss with my chiropractor the nature and purpose of

chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the

contents of this Consent.

I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal

adjustments. I intend this consent to apply to all my present and future chiropractic care. I reserve the right to

withdraw my consent at any time with verbal or written notice of such a decision.

Patient Signature: _______________________________

Signature of Witness:_____________________________

(or Legal Guardian if underage)

Print Patient Name:______________________________

Print Witness Name:_____________________________

Date:___________

Date:____________

Confidential Patient Information Page 3