Handley Chiropractic Clinic Patient Entrance Form (Page 5 of 5) in pdf

HANDLEY CHIROPRACTIC CLINIC

Dr. Leonard Handley, D.C.

PATIENT ENTRANCE FORM

727 Gardiners Road | Kingston, ON K7M 3Y5

(613) 384-1008 ●

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

Please read the following carefully and be sure to sign this document.

Doctors of chiropractic, medical doctors and physiotherapists who use manual therapy techniques such as spinal adjustments are required to advise patients that

there are or may be some risks associated with such treatment. In particular you should note:

While rare, some patients may experience rib fractures or muscle and ligament strains or sprains following spinal adjustments.

There are reported cases of injury to a vertebral artery following cervical spinal adjustments. Vertebral artery injuries have been known to cause stroke,

sometimes with serious neurological impairment and may, on rare occasion, result in serious injury. The possibility of such injuries resulting from cervical

spinal adjustment is extremely remote.

There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment, although no scientific study has ever demonstrated

such injuries are caused, or may be caused by spinal adjustments or chiropractic treatment.

Chiropractic treatment, including spinal adjustment, has been the subject of government reports and multi-disciplinary studies that have been conducted over many

years, and has been demonstrated to be effective treatment for spinal pain headaches and other similar symptoms. Chiropractic care contributes to your overall

well-being. The risk of injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments,

medications and procedures given for the same symptoms.

I acknowledge that I have discussed, or 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 adjustment. I intend this consent to apply to all my

present and future chiropractic care.

Dated this.................... day of ............................................................ ,20 ......... .

date

month

year

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Name of Patient (or Parent/Guardian)

Signature of Patient (or Parent/Guardian)

PLEASE PRINT CLEARLY

Dr. Leonard Handley, D.C.

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