Chiropractic Care Treatment Agreement and Informed Consent

Patient Information

Name: ___________________________ Date: _______________ Date of Birth: ____________________ Chart #: _____________

Agreement and Consent for Treatment

Nature of Chiropractic Treatment

I hereby authorize and consent to chiropractic treatment by Dr. _________________ and/or other licensed doctors of chiropractic who may be employed by or associated with this practice.

I understand that chiropractic treatment may include:

• Spinal manipulative therapy
• Physical examination
• X-ray studies (if indicated)
• Physical therapy modalities
• Therapeutic exercises
• Soft tissue techniques

Potential Benefits and Risks

Benefits may include:

• Relief of pain and discomfort
• Improved mobility and function
• Enhanced well-being
• Better posture and body mechanics

Potential risks and complications include but are not limited to:

• Soreness or stiffness following treatment
• Aggravation of symptoms
• Disc injuries
• Vertebrobasilar insufficiency (VBI)
• Fractures in cases of bone weakness

Financial Agreement

I understand that I am responsible for payment of all services rendered, regardless of insurance coverage or third-party liability.

Privacy Notice Acknowledgment

I acknowledge that I have received and reviewed the Notice of Privacy Practices.

Consent for Treatment

I have read and understand the above information and agree to the terms. I have had the opportunity to ask questions about this consent form and proposed treatment.

Signature: _________________________ Date: _______________

Witness: ___________________________ Date: _______________