Informed Consent to Chiropractic Adjustments and Care at Back-in-Action
Before we can start your treatment programme, we need to gain your consent for any procedures we apply. This means you need to be aware of any risks associated treatment. Please read this consent form carefully before your first consultation. If you are satisfied please sign. If you want to, you can discussany issues with your physician before signing.
Clinicians using manual therapy techniques, such as adjustment, manipulation or mobilisation, are required to inform patients that there are or maybe some rare risks associated with such treatment. In particular:
Treatments provided by this clinic, including spinal adjustment, manipulation and/or mobilisation; have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulders/arms/legs, headaches and other similar symptoms. Treatment provided at this clinic may also contribute to your overall well-being. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many medications and other treatment options often offered for such conditions.
I hereby request and consent to chiropractic adjustments and other therapy performed on me by my chiropractor or any other therapists working in this clinic, to the joints, ligaments, muscles and nerves of my spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs) and head.
I have revealed details on all my medical conditions and medications to the best of my knowledge and reported any history of substance abuse. I will refrain from the use of drugs or alcohol prior to treatment.
I have had an opportunity, if I wished to discuss the nature and purpose of chiropractic adjustments and other procedures in general and my treatment in particular as well as the contents of this consent. I understand that results are not guaranteed.I understand my chiropractor has many years of training in diagnosis and treatment. I do not expect the doctor of chiropractic to anticipate and explain all the risks and complications of treatment and I wish to rely on the doctor to exercise best judgement during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest.
I (Print name)……………………………………… confirm that I have received and understood the information given to me regarding my case, the proposed treatment and its implications and I hereby consent to treatment as per the plan outlined by my chiropractor. I intend this consent form to cover the entire course of treatment for my present condition and future treatment at the clinic.
Signature of Patient……………………………….. Date………………
(or Parent/Guardian)
Name of Witness/Translator……………………….Signature of Witness/Translator…………..…………
Name of Chiropractor……………………………..Signature or Chiropractor…………………………....