Chiropatic Intake Form (Page 5 of 5) in pdf

Informed Consent

Doctors of chiropractic, medical doctors and physiotherapists who use manual therapy

techniques such as spinal adjustments/manipulation are required to advise patients that there

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

A) While rare, some patients have experienced rib factures, muscle strains, or ligament

sprains following spinal adjustments/manipulation following certain manual therapy

procedures;

B) There are reported cases of stroke associated with visits to medical doctors and

chiropractors. Research and scientific evidence does not establish a cause and effect

relationship between chiropractic treatment and the occurrence of stroke. Recent studies

suggest that patients may be consulting medical doctors and chiropractors when they are

in the early stages of a stroke. In essence, there is a stroke already in progress. However,

you are being informed of this reported association because a stroke may cause serious

neurological impairment or even death. The possibility of such injuries occurring in

association with upper cervical adjustment is extremely remote;

C) There have been rare reported cases of disc injuries following cervical and lumbar spinal

adjustments/manipulation although no scientific study has ever demonstrated such an

injury is caused, or may be caused, by spinal adjustments/manipulation or chiropractic

treatment;

D) There are infrequent reported cases of burns or skin irritation in association with the use

of some types of electrical therapy offered by some doctors of chiropractic

Chiropractic treatment, including spinal adjustment/manipulation, has been the subject of

government reports and multidisciplinary studies conducted over many years and have been

demonstrated to be highly effective treatment for spinal pain, headaches and other similar

symptoms. Chiropractic care contributes to your overall health. The risk of injuries or

complication 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 I have discussed, or have had the opportunity to discuss, with my chiropractor

the nature and purpose of chiropractic and acupuncture treatment in general and my treatment

in particular, including spinal adjustment/manipulation, as well as the contents of this Consent.

I consent to the chiropractic/acupuncture treatments offered or recommended to my by my

chiropractor. I intend this consent form to cover the entire course of treatment for my present

condition and for any future condition(s) for which I seek treatment.

_______________________________

______________________________________

Patient’s Name (please print)

Signature of Patient (or Parent/Guardian)

_______________________________

______________________________________

Date (Day/Month/Year)

Witness / Verification of Signature

Chiropatic Intake Form Page 5