INFORMEDCONSENTTOCHIROPRACTIC/APPLIEDKINESIOLOGYTREATMENT
DoctorsofChiropracticwhousemanualtherapytechniquesarerequiredtoadvisepatientsthat
thereareormaybesomerisksassociatedwithsuchtreatment.Inparticularyoushouldnote:
a)Whilerare,somepatientsmayexperienceshorttermaggravationofsymptoms,ribfractures
ormuscleandligamentstrainsorsprainsasaresultofmanualtherapytechniques;
b)Therearereportedcasesofstrokeassociatedwithmanycommonneckmovements
includingadjustmentsoftheuppercervicalspine.Presentmedicalandscientificevidencedoes
notestablishadefinitecauseandeffectrelationshipbetweenuppercervicalspineadjustment
andtheoccurrenceofstroke.Furthermore,theapparentassociationisnotedveryinfrequently.
However,youarebeingwarnedofthispossibleassociationbecausestrokesometimescauses
seriousneurologicalimpairmentandmayonrareoccasionresultininjuriesincludingparalysis.
Thepossiblyofsuchinjuriesresultingfromuppercervicalspinaladjustmentisextremely
remote;
c)Thereisrarereportedcasesofdiscinjuriesfollowingcervicalandlumbarspinaladjustments
orchiropractictreatment.
Chiropractictreatment,includingspinaladjustments,hasbeenthesubjectofgovernment
reportsandmultidisciplinarystudiesconductedovermanyyearsandhasdemonstratedtobe
effectivetreatmentformanyneckandbackconditionsinvolvingpain,numbness,musclespam,
lossofmobility,headachesandothersimilarsymptoms.Chiropracticcarecontributestoyour
overallwellbeing.Theriskofinjuriesorcomplicationsfromchiropractictreatmentis
substantiallylowerthanthatassociatedwithmanymedicalorothertreatments,medications,
andproceduresgivenforthesametreatments.IacknowledgeIhavediscussed,orhavehad
theopportunitytodiscuss,withmychiropractorthenatureandpurposeofchiropractictreatment
ingeneralandmytreatmentinparticular(includingspinaladjustment)aswellasthecontentsof
thisConsent. 
Iconsenttothechiropractictreatmentsofferedorrecommendedtomebymychiropractor,
includingspinaladjustment.Iintendthisconsenttoapplytoallmypresentandfuture
chiropracticcare.
FINANCIALREPONSIBLITYANDATTENDANCE
Itisthepatient’sresponsiblitytopayforallservicesperformedintheclinic.Allpaymentisdue
onceservicesarerendered.Itisthepatient’sresponsiblitytomaintainappointments.The
patientmustnotifytheofficewithin24hoursifthereisaschedulechangeorcancellation,
otherwisethepatientwillbebilledinfullforthatappointmenttime.Thisawellnessclinicand
therearemanypatientsthatwouldbenefitfromcareintheclinic.Givingpropernoticeallowsfor
otherpatientstoreceivecarethatmaybeneeded.Allappointmentsarescheduled,thereareno
walkins,soitisveryimportantthatpatientsrespectthisresponsiblityandbecourteous. 
Signature:____________________________________Date:___________________
Full name: _________________________________