INFORMED CONSENT TO CHIROPRACTIC CARE

Camp Hill Family Chiropractic

3401 Hartzdale Drive, Suite 117

Camp Hill, PA 17011

717-761-8840

 

Please discuss any questions or concerns with the Doctor before signing this consent.

 

I hereby request and consent to the performance of Chiropractic adjustments and other Chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below for whom I am legally responsible) by the doctor of chiropractic named in this document.

 

I have had the opportunity to discuss with the doctor and/or any other office or clinic personnel the purpose and benefits of the Chiropractic adjustments and other treatments listed below.  Any alternatives to treatment have been review.

 

Though Chiropractic adjustments and treatments are usually beneficial and seldom any problem. I understand and am informed that there may be some risks to treatment.  Risks include, but are not limited to, fractures, disc injuries, strokes, dislocations, sprains, strains, muscle and/or joint tenderness.  I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and is in my best interest.  I understand that chiropractic is not an exact science, and that by being treated in this clinic that it does not guarantee results.

 

I understand that I may be receiving any of the following treatments:

·        Chiropractic Adjustments (hands-on and with low force instruments)

·        Radiograph Diagnostic X-rays.

·        Flexion and Distraction Tractioning of the Spine.

·        Cervical Traction.

·        Ice and/or Heat.

·        Rehabilitation Strengthening and Stretching Exercises.

 

X-RAY CONSENT FORM

The doctor has explained that the purpose of the x-rays about to be taken is to analyze the spine for vertebral Subluxations and to determine the appropriateness of Chiropractic spinal adjustments.  If the doctor discovers a non-Chiropractic “unusual finding” when reviewing this x-ray, I will be informed.  I then must determine if I should seek the services of an additional health care provider for advice, diagnosis, or treatment for the unusual finding.  I understand that seeking advice from another type of health care provider should not interfere with the Subluxation corrective care provided by this office.  Please Note: Your X-rays are a document of your file and the property of this office.

 

FEMALES: If you think that you may be pregnant, notify the doctor, as x-rays cannot be taken at this time.

 

I fully understand the above and consent to Chiropractic spinal x-rays.  Patient Initials                 

 

I have read or have had read to me, the above consent.  I have also had the opportunity to ask questions, and that all of my questions have been answered to my satisfaction.  I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment.

 

Patient Name:                                                                                      Date:                   

Patient Signature:                                                                                 Date:                   

Signature of Parent/Guardian:                                                                Date:                    

Staff Signature:                                                                                    Date: