Informed Consent .pdf

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Patient Name: ___________________________________
DOB: __________________________________________

Acct#____________________________________
Claim#___________________________________

INFORMED CONSENT TO CHIROPRACTIC TREATMENT
I, _______________________________________________________________, do hereby give my consent to the performance of chiropractic adjustments and
other chiropractic procedures, and, if necessary, diagnostic x-rays on me (or on the patient named below, for whom I am legally responsible:
________________________________________). I understand that the procedures may consist of manipulations/adjustments involving movement of
the joints and soft tissues, specific exercises or stretches, and x-rays.
I further understand that such chiropractic services will be performed by Dr. Scott Conklin and/or other licensed Physicians of Chiropractic
who may treat me now or in the future at this office. I have had an opportunity to discuss with Dr. Scott Conklin and/or other office or clinic
personnel the nature and purpose of chiropractic adjustments and other procedures.
Although spinal manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal
problems, I am aware, as with most medical procedures, that there are possible risks and complications associated with these procedures as
follows:
Soreness: I am aware that, like exercise, it is common to experience muscle soreness in the first few treatments.
Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. If dizziness or nausea occurs, I will immediately
advise my doctor.
Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies, like weak bones
from osteoporosis, may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this
office will proceed with extra caution.
Stroke/Vertebral dissection/TIA: Although such medical conditions happen with some frequency in our world, the most current research
on the topic and on chiropractic care indicates that there is a very weak associative relationship and it is extremely rare and remote. Patients
with such outcome appear to have a pre-existing medical condition. I am aware that nerve or brain damage including stroke is reported to
occur once in one million to once in ten million treatments.
I understand that Dr. Conklin will make every reasonable effort during the examination to screen for contraindications to care; however, I
will do my best to provide complete information about past and present conditions, and to notify him of any changes in condition.
TREATMENT RESULTS
I understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and
function, and reduced muscle spasm. However, I appreciate there is no certainty, as with any medical procedure, that I will achieve these
benefits. I agree to the performance of these procedures by my doctor and other such persons of the doctor’s choosing.
ALTERNATIVE TREATMENTS AVAILABLE
Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, exercise, co-treating
with other physicians or specialists, and possible surgery.
I have read or have had read to me the above explanation of chiropractic treatment, alternatives, and risks. Any questions I had
regarding these procedures have been answered to my satisfaction. I have made my decision voluntarily and freely.

To be completed by the patient:
________________________________________________________________________________
Patient’s signature OR signature of representative *

Date:__________________________________________

*To be completed by the patient’s representative, if necessary, (e.g. if the patient is a minor or is physically or mentally
incapacitated)

________________________________________ Date:____________________ I have had a PARQ discussion with this patient and obtained consent to treatment.
Total Family Chiropractic, PC D. Scott Conklin, DC 4309 SE Woodstock Blvd #120 Portland, OR 97206

503-777-4221


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