PATIENT: Please discuss any question or concerns with the Doctor before signing.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient listed below, for whom I am legally responsible) by the doctors and staff of Priority Health Chiropractic.
I understand that chiropractic treatment is a procedure that involves movement of joints and soft tissue and that physical and exercise may also be prescribed.
I have had the opportunity to discuss with the doctor and/ or other clinic personnel the purpose and benefit of the chiropractic treatment and other treatments listed below. Alternatives to chiropractic care, which include rest, exercise, physical therapy, over the counter medications, medical treatment (drug therapy/surgery), as well as non-treatment, have been reviewed. The disadvantages to these approaches have been explained to me.
Although chiropractic adjustments are considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, l understand and am informed that there are some risks to treatments. Risks include, but are not limited to, additional soreness, dizziness, fractures, nerve tissue damage, disc injuries, strokes, dislocations, sprains/strains, and skin irritation/burn. The probability of serious complications has been estimated at less than one in a million.
The risks associated with remaining untreated have been explained to me. These may include, but are not limited to, decreased mobility, increased pain/symptoms, scar tissue/adhesion formation, ossible nerve damage, increased inflammation and degenerative changes. It is possible that delaying treaiment will complicate future care.
In the interest of better serving our patients, we send all of x-rays to a licensed radiologist for review. We have negotiated a special rate of $40 for this service, which is a significant savings over standard fees. Because this service is not covered by insurance, this fee will be added to your account.
If you are unable to make an appointment please call us before your appointment to reschedule it so that it can be rescheduled at a later time. Failure to do so will result in a $25.00 no show fee.
I understand that chiropractic is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.
I understand that my treatment will consist of Chiropractic adjustments and/or physical therapy.