I hereby request and consent to the performance of chiropractic procedures, including various modes of physio-therapy, diagnostic x-rays, and any supportive therapies 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 and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I have had an opportunity to discuss with the Doctor of Chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. Not only is this a consent document, but an opportunity to ask questions and be educated about the body. 

I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure.  I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, neck artery dissections, strokes, dislocations , sprains and nervous system reprocessing. 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, is in my best interests. Below are definitions and descriptions of the risks mentioned above to empower one’s body.

Nervous System Reprocessing: After an adjustment you may feel hazy, euphoric or tired. This is the body asking for rest. If this occurs, take a walk around the block or rest a little longer before driving or biking away from the office.

I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. Subluxation is when a bone is tilted, inhibiting nerve performance. Chiropractic can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures.  However, like all other health modalities, results are not guaranteed and there is no promise to cure.  Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment, except for credit card processing fees.

I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited to self-administered,  over  the  counter  analgesics  and  rest;  medical  care  with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

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