Chiropractic New Patient Intake Form

Informed Consent Document
Patient's Name*

First NameLast Name
To the Patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

Analysis/Examination/Treatment

As a part of the analysis, examination and treatment, you are consenting to the following procedures: spinal manipulative therapy (if deemed safe and suitable to your condition), palpation, range of motion testing, orthopedic testing (trying to physically recreate your symptoms to help with diagnosis), basic neurological trsting, muscle strength testing, postural analysis testing, soft tissue massage, therapeutic exercise.

The risks inherent to 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 strains. Some types of manipulation of the neck has been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Stroke caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote.

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 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, injections, painkillers

--Acupuncture, massage therapy

--Surgery

If you choose to use one of the above noted "other treatment" options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physicians.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. By signing below I state 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.
Date*

MonthDayYear
Date
Patient's Name*
Signature*

Clear
CONSENT TO TREATMENT (MINOR):

I hereby request and authorize Dr. Jason Potash to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter.

As of this date I have the legal right to select and authorize healthcare services for the minor child named above (if applicable). Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this, care should be revoked or modified in any way, I will immediately notify this office.
Signature of Parent or Guardian (if a minor):

Clear
Should be Empty:

Atkinson Family Practice Chiropractic Intake Form

Informed Consent Document