To the patient: Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. Please ask us questions about anything that may be unclear before you sign this form.
As part of the analysis and examination, you are consenting to the performance of procedures and/or specific tests including but not limited to the following:
basic neurological testing
manual muscle strength testing
range of motion testing
referral for further imaging or laboratory testing as needed
The Chiropractic Adjustment:
Spinal manipulative therapy involves the doctor using his or her hands as a mechanical instrument upon your body in such a way as to restore motion to your joints. This may cause an audible “pop” or “click,” and you may feel a sense of movement. As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulative therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, and stroke. Some patients may experience stiffness and soreness following the first few days of treatment. The doctor will make every reasonable effort during the examination to screen for contraindication to care; however, if you have a condition that would otherwise not come to the doctor’s attention, it is your responsibility to inform the doctor. Fractures are rare occurrences and generally result from some underlying weakness of the bone, which will be checked for during the taking of your history, physical examination, and/or x-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.
As part of the treatment, you are consenting to the performance of procedures including but not limited to the following:
spinal manipulative therapy
deep muscle therapy
sound and color therapy
soft tissue manipulation
prescription of dietary supplements or herbs
Alternative Treatment Options:
Other treatment options for your condition may include self-administered over-the-counter analgesics and rest, medical care and prescription drugs, hospitalization, and surgery. You should be aware that there may be risks and benefits associated with such options and you may wish to discuss these with your physician. Remaining untreated may allow the formation of adhesions and reduces mobility, which sets up a pain reaction further reducing mobility. Over time, this process may complicate treatment, making it more difficult and less effective the longer it is postponed. Postponing conservative or prophylactic care may result in the eventual development of complications and/or pathology necessitating medical intervention or critical care.
I have read or have had read to me the above explanation of the chiropractic adjustment as well as related treatments and examination procedures. I have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.
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