Informed Consent for Chiropractic Adjustment

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 indicated below and/or other licensed doctors of chiropractic or those under their supervision.

Possible Risks and Complications:

• I understand and am informed that, as in the practice of medicine, there are some risks to treatment, including, but not limited to: muscle soreness, sprains/strains, fractures, disc injuries, stroke or stroke-like symptoms, and aggravation of pre-existing conditions.
• I do not expect the doctor to be able to anticipate and explain all the 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, is in my best interest.

Nature and Purpose of Chiropractic Procedures:

I have had the opportunity to discuss with the doctor the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

Consent

I have read, or have had read to me, the above explanation. I have had an opportunity to ask questions about its content, and by signing below I consent to the proposed procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.