Chiropractic Treatment Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Date: _________________________ Chart #: _________________

Nature of Chiropractic Treatment

I hereby request and consent to chiropractic treatments and other procedures within the scope of practice of chiropractic care by the doctor(s) at [PRACTICE NAME] and/or other licensed doctors who now or in the future treat me while employed by, working or associated with, or serving as back-up for the doctor(s) at [PRACTICE NAME].

Understanding of Treatment

I understand that:

1. The practice of chiropractic includes many standard examination and testing procedures, including:

   • Physical examination
   • Spinal manipulation/adjustment
   • Range of motion testing
   • Orthopedic and neurological testing
   • Palpation
   • Specialized instrumentation

2. Treatment may involve moving different joints and tissues using various degrees of pressure.

Potential Risks

I understand and acknowledge that:

• As with any healthcare procedure, there are certain complications that may arise during chiropractic manipulation and therapy
• These complications include but are not limited to:
  • Muscle strain
  • Ligament sprain
  • Rib injury
  • Disc injuries
  • Fractures
  • Cervical myelopathy
  • Costovertebral strains and separations

Special Considerations

I will inform the doctor if I:

• Am pregnant
• Have been diagnosed with osteoporosis
• Have a history of spinal surgery
• Have any other condition that may affect my treatment

Acknowledgment and Consent

I have read, or have had read to me, the above explanation of chiropractic treatment. I have discussed any questions or concerns with the doctor and have had these answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and hereby give my consent to receive treatment.

Patient Signature Date

Witness Signature Date