Chiropractic care has a very low-risk profile, especially when compared with more invasive methods of spinal healthcare however, all forms of chiropractic treatment have the potential for adverse reactions in some people.
Please read the following carefully:
1. I acknowledge the rare risks associated with my care which include but are not limited to muscle and joint soreness or strains, nausea and dizziness, fractures, disc injuries including disc encroachments/ruptures, causing nerve irritation and referred symptoms, strokes (or like episodes) and an exacerbation and/or aggravation of my underlying condition. Such risks may result in outcomes such as referral, further tests, surgery, incapacity, and the like.
2. I will have the opportunity to discuss my proposed care with my practitioner.
3. I also acknowledge that I will have the opportunity to ask questions about the nature, extent, and purpose of the proposed care and that I have been given sufficient time to make a decision giving consent for the care to proceed.
4. I acknowledge that I am aware of and understand the potential risks. I appreciate that results are not guaranteed.
5. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care. I hereby acknowledge my consent to the performance of the proposed care at Chiro & Sports Med and/or any practitioner working in this clinic.
6. In very rare circumstances, some treatments of the neck may damage a blood vessel and lead to stroke or related symptoms (current statistics eg between 1 in 2 million to 1 in 5.85 million Haldeman, et al. Spine vol 24-8 1999). Other possible risks include strain/injury to a ligament or a disc in the neck (current statistics eg less than 1 in 139,000) and the low back (current statistics eg 1 in 62,000 Dvorak study in Principles & Practice of Chiropractic, Haldeman 2nd Ed.). For some patients especially with bone weakening diseases, a fracture of a bone although rare is possible.”
7. I understand that I can discuss any concern with my treating practitioner at any and all consultations I may have, and I can withdraw consent at any time.