INFORMED CONSENT AGREEMENT

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THE NATURE OF THE CHIROPRACTIC ADJUSTMENT

    The primary treatment used by doctors of chiropractic is spinal manipulative therapy. This procedure will be used to treat you. The doctor may use his hands or a mechanical instrument on your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much like “cracking” your knuckles. A sense of movement may be felt.

ANALYSIS / EXAMINATION / TREATMENT

    As a part of analysis, examination and treatment, you are consenting to all or some of the following procedures on an as needed basis:

Spinal manipulative therapy, Range of motion testing, Nutritional counseling, Radiographic studies, Rehabilitative exercises, Palpation, Orthopedic testing, Muscle strength testing, Interferential, Infrared light therapy, Vital Signs, Ultrasound, Whirlpool, Traction, Hot/cold therapy, Postural analysis, Neurological testing, Pulsed Electro Magnetic Field, Non-Surgical Decompression, MLS laser therapy

THE MATERIAL RISKS INHERENT IN CHIROPRACTIC ADJUSTMENT

    As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The doctor will make every reasonable effort during the examination to screen for contraindications to care; however if you have a condition that would otherwise not come to the doctor’s attention, it is your responsibility to inform the doctor.

THE PROBABILITY OF RISKS OCCURRING 

    Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history, your examination and your x-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

THE AVAILABILITY AND NATURE OF OTHER TREATMENT OPTIONS

    Other treatment options for your condition may include:

  • Self-administered, over the counter analgesics and rest
  • Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
  • Hospitalization
  • Surgery

THE RISKS AND DANGERS ATTENDANT TO REMAINING UNTREATED

    Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Leaving spinal problems untreated may cause or contribute to arthritis, disc lesions, structural problems, pinched nerves, muscle weakness and wasting, adhesions, muscle spasm, swelling and chronic pain.

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I have read the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. James P. Perkins and have had my questions answered to my satisfaction. By marking below, I am stating that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. *
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