This form is intended to educate you on the risks and benefits of receiving care in our center so that you can make an informed decision as to whether you consent to that care. Please read this form carefully so you can fully understand the inherent risks and benefits. Your signature at the bottom of this form indicates your full understanding of those benefits and risks, and constitutes your full consent to all chiropractic and ancillary treatment in our center until the time you indicate otherwise. If you have questions or concerns about treatment in our center, do not sign this form until those questions or concerns have been addressed to your satisfaction.
Treatment: Treatment in our center may include chiropractic adjustments (sometimes called manipulations), soft tissue therapies, massage, therapeutic exercise, joint mobilizations, superficial heat packs, stretches, lifestyle coaching/counseling, and modalities such as electrical stimulation and low level laser therapy. The most common side effect of these treatments includes mild soreness, redness of the skin, headaches, or mild bruising that resolves on its own, and that can last from hours to days. More severe adverse events that have been associated with spinal adjustments/manipulations include rib or spinal fractures, irritation of pre-existing spinal disc herniations/bulges, and strokes. These more severe adverse events are very rare (1 in several hundred thousand to 1 in several million adjustments/manipulations), and are associated with pre-existing conditions such as pre-existing fractures, cervical artery tears, and severe osteoporosis. Please fill out your patient intake forms thoroughly to notify your chiropractic physician of any pre-existing medical conditions and injury history. If you have any of these conditions, a modified treatment approach may still be possible and appropriate in our center. Reports in the news and elsewhere have been made about chiropractic care and cervical artery dissections leading to stroke.
The most comprehensive and recent research on this topic indicates that during a chiropractic adjustment the cervical artery undergoes about the same amount of strain as when you turn your head to the side (trying to look over your shoulder), and that you are no more likely to suffer a cervical artery dissection or stroke after seeing a chiropractor than when you see a medical doctor. The most recent research tells us that the care given by chiropractors is the safest and most effective care for many conditions including chronic musculoskeletal pain, back pain, neck pain, headaches, and more when compared to alternatives such as pharmacological and surgical treatment.
Other treatment options: The chiropractic physicians in our center will not hesitate to advise other treatment options or consultations when appropriate. This may include referrals for additional diagnostic imaging (CT, MRI), medical consultations for pharmacologic treatment, surgical consultations, or physical/occupational therapy.
X-rays: If clinically appropriate, x-rays may be taken during the course of your care in our facility. X-rays do result in some radiation exposure, so please inform the doctor if you have any condition where x-rays may not be appropriate such as pregnancy or current radiation treatment.
(Must be 19 years of age or Legal Guardian must sign)
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