Chiropractic Care Authorization and Consent for Treatment

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I hereby authorize the licensed chiropractor(s) at [PRACTICE NAME] and their support staff to perform diagnostic tests, including but not limited to radiographs, and to administer treatment as is necessary.

Understanding of Treatment

• I understand that, like all forms of healthcare, chiropractic treatment has some risks and limitations.
• The most common side effects include:
  • Temporary soreness or stiffness
  • Mild to moderate discomfort following treatment
  • Skin irritation from therapy or taping procedures

Acknowledgment of Risks

While rare, I understand that more serious complications may include:

• Disc injuries
• Cervical (neck) complications
• Stroke-like symptoms
• Burns from physiotherapy devices

Financial Responsibility

I understand that I am financially responsible for all charges whether covered by insurance or not. I hereby authorize the release of any medical information necessary to process insurance claims.

Certification

I certify that the information provided is correct to the best of my knowledge. I will not hold my doctor or any staff member responsible for any errors or omissions that I may have made in the completion of this form.

Signature: _________________________ Date: _____________

Witness: ___________________________ Date: _____________

Office Use Only

Reviewed by: _______________________ Date: _____________ Notes: _______________________________________________