INFORMED CONSENT FOR CHIROPRACTIC CARE
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
PURPOSE
The purpose of this document is to obtain your consent for chiropractic evaluation and treatment provided by the doctors and staff at Frain Family Chiropractic Wellness Center. Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if anything is unclear.
TYPES OF CARE PROVIDED IN THIS OFFICE
Chiropractic care involves the assessment and treatment of the spine and other joints of the body, as well as associated soft tissues (muscles, ligaments, and nerves). Treatments may include but are not limited to:
Chiropractic Adjustments
Therapies such as EMS and Class IV laser therapy
Soft tissue techniques (e.g. massage, stretching, trigger point therapy)
Rehabilitative exercises
Lifestyle and ergonomic advice
Nutritional Counseling and supplement recommendations
POTENTIAL SIDE EFFECTS/RISKS ASSOCIATED WITH CHIROPRACTIC CARE
As with any healthcare procedure, there are potential risks associated with chiropractic treatment. These may include but are not limited to: temporary soreness or stiffness, headaches, dizziness or lightheadednes, muscle strains or sprains, rib fractures (rare), aggravation of underlying conditions. Although extremely rare, more serious complications such as stroke, disc herniation, or nerve injury have been reported. The risk of such complications is considered to be very low and comparable to other forms of manual therapy. The doctors in this office utilize techniques that involve no twisting of the spine, which all but eliminates this risk.
ALTERNATIVE FORMS OF CARE
Alternatives to chiropractic care may include medical care (e.g., medications, physical therapy, injections, or surgery), rest, or doing nothing. Risks and benefits of these options should be discussed with your primary care physician or surgeon prior to treatment.
RISKS AND DANGERS OF REMAINING UNTREATED
If left untreated, some conditions can result in the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time, this process may complicate treatment making it more difficult and less effective.
CONSENT TO EVALUATION AND TREATMENT
I understand that healthcare in general, is not an exact science and that no guarantee can be made regarding the outcome of my treatment.
I understand that the doctor will explain all procedures and answer any questions I may have.
I understand that I can refuse treatment at any time.
I understand that I have the right to seek a second opinion or terminate care at my discretion.
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Frain Family Chiropractic Wellness Center to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter:
This authorization also extends to all other doctors and staff members and is intended to include radiographic examination at the doctor’s discretion.
For divorced/separated parents/guardians: As of this date, I have the legal right to select and authorize health care services for the minor child named above under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office.
CONSENT TO TREATMENT
By signing below:
I acknowledge that I have read and understood the information provided above.
I have had the opportunity to ask questions and receive satisfactory answers.
I give my voluntary consent to receive chiropractic evaluation and treatment.
