Chiropractic Care Agreement and Informed Consent

Patient Information

Name: _______________________________ Date of Birth: ________________________ Contact Number: ______________________

Agreement Terms

1. Consent for Treatment

I hereby authorize and consent to chiropractic examinations, x-rays (if necessary), and treatment provided by [Practice Name] and its associated healthcare providers. I understand that:

• Chiropractic treatment involves manual adjustment of joints and soft tissues
• The treatment may include various therapeutic modalities
• Results are not guaranteed
• Alternative treatment options have been explained to me

2. Risks and Benefits

I acknowledge that I have been informed of the following:

Potential Benefits:

• Pain relief
• Improved mobility and function
• Enhanced well-being
• Better posture

Potential Risks:

• Temporary soreness
• Mild stiffness
• Rare complications including but not limited to:
  • Disc herniation
  • Vertebral artery dissection
  • Fracture in compromised bones

3. Financial Agreement

• I understand that payment is due at the time of service
• I am responsible for all charges regardless of insurance coverage
• Missed appointments without 24-hour notice may incur a fee

4. Privacy Notice

I acknowledge receipt of the Notice of Privacy Practices (HIPAA).

5. Communication Consent

I consent to receive communications regarding appointments and care via:

• Phone: □ Yes □ No
• Email: □ Yes □ No
• Text: □ Yes □ No

Signatures

Patient Signature: ___________________ Date: __________

Provider Signature: __________________ Date: __________

Witness Signature: __________________ Date: __________