Reassessment Form (Page 3 of 3) in pdf

CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION

Informed Consent to Chiropractic Treatment

FORM L

There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic.

In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or

sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to

occur following certain manual therapy procedures;

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and

scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the

occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors

when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are

being informed of this reported association because a stroke may cause serious neurological impairment or even

death. The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote;

c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment,

although no scientific evidence has

demonstrated such injuries are caused, or may be caused, by spinal

adjustments or other chiropractic treatment;

d) There are infrequent reported cases of burns or skin irritation in association with the use of some types of

electrical therapy offered by some doctors of chiropractic.

I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my

chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment

options and recommendations for my condition, and the contents of this Consent.

I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal

adjustments.

I intend this consent to apply to all my present and future chiropractic care.

Dated this _____________ day of_________________________, 20______.

____________________________________

__________________________________

Patient Signature (Legal Guardian)

Witness of Signature

Name:_______________________________

Name:_____________________________

(please print)

Dr. Jennifer Heick

& Dr. Rebecca Blackburn

550 Parkside Drive, Unit A4, Waterloo ON N2L 5V4

519-746-3838 | |

Reassessment Form Page 3