hereby request and consent to the performance of chiropractic procedures, including a comprehensive exam, diagnostic testing, physical therapy techniques, manual therapy, adjustments or manipulation on me which are recommended by the doctors at Accident and Injury Chiropractic and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by or associated with Accident and Injury Chiropractic.
Accident and Injury Chiropractic, including its doctors and staff, will not be held responsible for any pre-existing medically diagnosed conditions, nor for any medical diagnosis.
I understand that, as with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. Although these complications are rare, they include but are not limited to, muscle sprain/strains, dislocations, fractures, costovertebral strains, and separations. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke.
I understand that, as with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. Although these complications are rare, they include but are not limited to, muscle sprain/strains, dislocations, fractures, costovertebral strains, and separations.
Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Although our patients are screened for indications that they are candidates for chiropractic
manipulation to the best of our ability, I do not expect the doctor to be able to anticipate all risks and complications during the course of the procedure(s).
Therefore, the doctor based upon the facts then known, will act in the best interest of the patient. I understand that I can terminate at any time, even during the course of any of the chiropractic procedures listed above.
At Accident and Injury Chiropractic treatment is often given in an open room concept. Should I need to speak with a doctor at any time in private, I understand that the doctor will provide a room for these conversations. Please feel to ask at any time for such accommodations.
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
The right to review the notice prior to signing this consent.
The right to object to the use of my health information for directory purposes.
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.
