Informed Consent

Informed Consent

We encourage and support a shared decision-making process between us regarding your health needs. As a part of that process, you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent.

Chiropractic is based on the science, which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health.

Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations.

Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation.

A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation, radiological examination (x-rays), and laboratory testing.

The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in the management protocol. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.

Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. Risks associated with physiotherapy may include the preceding as well as allergic reaction and muscle and/or joint pain. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.

Licensed Massage Therapy

The techniques used during the session will consist of Swedish, Deep Tissue, Trigger Point Therapy, Myofascial Release and Manual Ligament Release.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or another qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Spinal Decompression Therapy

The nature of the spinal decompression: You will be harnessed in with 2 separate harnesses and your spine will be gently lengthened in order to decompress herniated or bulging discs or re-hydrate degenerated discs.

The material risks inherent with spinal decompression: As with any healthcare procedure, there are certain complications that may arise during spinal decompression. This may include strains, muscle spasms, disc injuries and worsening of your pain. This list is not all-inclusive.

The probability of those risks: The complications listed are considered rare. The most common risk is a dull, achy soreness similar to having just worked out for the first time in a long time. This is usually due to stretching of tight muscles that haven’t been stretched in this way. This will typically go away within the first week or two of treatments. We will warm the tissues up before treatment and will decompress your spine more conservative at first to prevent as much soreness as we can. It is recommended that you ice for 20 minutes up to 3 times daily for the first week to decrease pain and soreness.

Ancillary treatments recommended: Ice, moist heat packs, cold laser therapy, stretching/strengthening exercises and massage therapy.

Risks involved with the recommended ancillary treatments: Ice and/or heat can cause burning if used inappropriately. Stretching/strengthening exercises and non-surgical spinal decompression can cause temporary post-treatment soreness or reflex muscle spasms. This list is not all-inclusive.

Other treatment options for your condition can include medical care with prescription drugs, self-management with over-the-counter medication, rest, and/or surgery. There are material risks inherent in each of these options including but not limited to: addiction to medication, side effects of medication, improper self-dosages and surgical risks including complications from either the procedure or the anesthesia.

Cold Laser Therapy

Cold Laser, also referred to as Low Level Laser Therapy, is a procedure regarded as one of the most cost-effective and safest of the healing arts. There are no known side effects of phototherapy. It is recommended, however, that this form of treatment not be used over and around the uterus during pregnancy; where there are active ongoing hemorrhaging/bleeding tendencies; when there is any indication or diagnosis of blood clots; over and around the thyroid gland; cancer (tumors or cancerous areas); over the cardiac region and vagus nerve; where analgesia/pain relief may mask progressive pathology; over an area that has been treated with a photosensitizing agent; in a patient taking medication that may cause sun-sensitivity (including some antibiotics & St. John’s Wort); in a patient with epilepsy (pulsed light therapy); over the growth plates in children; or direct irradiation of the eyes.

I hereby consent to the application of Cold Laser/Low Level Laser Therapy on me. 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 initially below, I agree to the procedures. I understand that there are no guarantees with any type of treatment as it is dependant upon each individual’s ability to heal. I intend this consent form to cover the entire course of care for my present condition(s) and for any future conditions(s) for which I seek care. I am financially responsible for all services.

Nutritional and Herbal Supplements

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally. In this office, we provide nutritional counseling and make individualized recommendations regarding the use of these substances in order to upgrade the quality of foods in a patient’s diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.

Nutritional and Herbal Supplements

You are under no obligation to purchase nutritional supplements at our clinic.

As a service to you, we make nutritional supplements available in our office. We purchase these products only from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering:

(1) the quality of the science behind the product

(2) the quality of the ingredients themselves

(3) the quality of the manufacturing process

(4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results.

While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.

If you have concerns about this issue, please discuss them with our staff.

I have been informed of the nature and purpose of chiropractic care, massage therapy, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Additionally, I have read and agree with the policy on nutritional supplementation and as the consumer, will ensure that I take responsibility in reading the product ingredients, making sure that I am not allergic to any of the product contents.

Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.


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