INFORMED CONSENT TO CHIROPRACTIC TREATMENT* I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my
circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.
SIGN ONLY AFTER YOU UNDERSTAND AND AGREE TO THE ABOVE
You are the decision maker for your health care. Part of our role is to provide you with information to assist you in
making informed choices. This process is often referred to as “informed consent” and involves your understanding
and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and
the potential effect on your health if you choose not to receive the care.
We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will
be carefully performed but may be uncomfortable.
Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive
procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to
reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint
motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological
functioning and overall well-being.
It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no
promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited
to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns
and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and
ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is
a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of
an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-
4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition
often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a
percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically
adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of
stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in
two million cervical adjustments.
It is also important that you understand there are treatment options available for your condition other than
chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but
are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care
with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second
opinion and to secure other opinions about your circumstances and health care as you see fit.