Informed Consent For Chiropractic Care printable pdf download

Informed Consent for Chiropractic Care

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be

working for the same objective. It is important that each patient understand both the objective and the method that will

be used to attain it. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed

about the condition of your health and the recommended care and treatment to be provided so that you may make the

decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives.

Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine)

and function (primarily the nervous system) as that relationship may effect the restoration and preservation of health.

Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24

vertebrae in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve

function and interference to the nervous system. This may result in pain and dysfunction or may be entirely

asymptomatic.

Subluxations are corrected and/or reduced by an adjustment. An adjustment is the specific application of forces to

correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the

spine. Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary

procedures such as physiotherapy and/or rehabilitative procedures may be included.

If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings

and recommend that you seek the services of another health care provider.

All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete

satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I

have read and fully understand the above statements and therefore accept chiropractic care on this basis.

___________________________________ __________________________________ _______________

Print Name

Signature

Date

Consent to evaluate and adjust a minor child:

I, _________________________ being the parent or legal guardian of ______________________________

have read and fully understand the above Informed Consent and hereby grant permission for my child to

receive chiropractic care.

Pregnancy Release:

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her

associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be

hazardous to an unborn child.

Date of last menstrual cycle: _______________________________________

______________________________________________________________

______________________

Signature

Date

Informed Consent For Chiropractic Care