Consent Form

To Our Patients:

Chiropractic examination and therapeutic procedures (including spinal adjustment, heat application, and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. Side effects include, but are not limited to, soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare and their association with spinal adjustments (manipulation) is debated. These complications include injury to the arteries in the neck which may be associated with stroke and serious neurological impairment, injuries to the spinal discs, and spinal fractures. Serious complications are estimated to be in the range of .5 – 2 incidents per million for adjustments of the neck, and 1 per million for adjustments of the low back. Additional information on side-effects, complications and effectiveness of spinal adjustments is available upon request.

I have read and understand the above statements regarding treatment side-effects. I also understand that there is no guarantee or warranty for a specific cure or result.

Patient signature	Date

Please read the following carefully and initial each statement.

Chiropractic care is the science, philosophy, and art of locating and correcting spinal subluxations (misalignments) and as such, is oriented towards improvement of spinal function relative to range of motion, muscular and neurological aspects. There has been no promise, implied or otherwise, of a cure for any symptoms, disease, or condition as a result of treatment in this clinic. I have, to the best of my knowledge, provided the chiropractor with a complete and accurate health history. I have had the opportunity to discuss with the chiropractor the nature and purpose of chiropractic adjustments and other procedures as well as other concerns. I understand the results are not guaranteed. I intend this consent form to cover the entire course of my chiropractic care for this and any future presentation. I understand that if I have any prosthetics or surgical implants (including breast implants, an artificial joint, etc.), I should discuss this with the supervising physician because it may affect care. I understand that I play an important role in my own health care. Just as a patient can choose to discontinue care at any time, Twisted Chiropractic reserves the right to terminate a doctor-patient relationship if a patient is continually unable to comply with reasonable treatment plans.

I have read and understand the information above. I give my permission and consent to chiropractic examinations, adjustments, and other chiropractic procedures wherever the chiropractor determines necessary. By signing below I agree to chiropractic care.

Patient signature	Date