It has been brought to my attention that it is not uncommon for some patients to have mild increased discomfort after an adjustment.
If I feel any discomfort I will apply ice to that area and rest as directed. If I am concerned at all about the discomfort or start to develop any new symptoms, I am aware that I can call the clinic phone number 24 hours a day. If no one answers, I am to leave a message with a call back number. If I am unable to contact the doctor right away or if I am out of town I can present myself to the emergency room.
If any tests were performed outside of this office (i.e. x-rays, laboratory, or other diagnostic procedures) I understand that the doctor will review the results with me at my next scheduled appointment or when the reports become available.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various methods of physical therapy, stretching, and ultrasound and/or electric stimulation, on me by the doctor of chiropractic in this office or anyone working in this clinic whom is authorized by the doctor of chiropractic.
I further understand and have been informed that, as in all health care, in the practice of chiropractic there are some very slight risks to treatment that include, but are not limited to, muscle sprains/strains, disc injuries, and strokes. I do not expect the doctor to be able to explain or to anticipate all the risks and complications. I wish to rely on the doctor to exercise judgment throughout the course of the procedure in which the doctor feels at that time based upon facts known, is in my best interest.
I have read the above consent, and by signing below, I agree to the above-mentioned procedures. I intend this consent form to cover the entire course of my treatment for the current condition I have and for any future condition for which I seek treatment.
Patient’s Signature: ________________________________ Date: __________________
Parent/Guardian Signature: __________________________ Date: __________________
Witness’ Signature: ________________________________ Date: __________________
Phone 386-761-0520 · Fax 386-761-0553