On occasion, some patients experience increased discomfort following chiropractic care and examination. Chiropractic physical examination and treatment may involve bending and physically challenging joints and soft tissues (e.g. muscles and ligaments) of the spine and extremities, and it can possibly lead to temporary feelings of soreness or pain. During treatment, the Doctor may use their hands or mechanical devices to move, adjust or manipulate joints and mobilize soft tissues. With certain soft tissue therapies, light to moderate bruising may also occur. This is nearly always a temporary issue that occurs while the area under care is undergoing therapeutic change. Patients reserve the right to consent to or refuse certain aspects of care once therapeutic options have been presented.

    I understand and have been informed that there are risks of side effects and complications anytime a healthcare provider is asked to intervene in an encounter with a patient. I have been informed of the following: that although the risk of serious complications from chiropractic treatment are rare and unlikely, events ranging from soreness, sprains and strains to fracture or dislocation to injuries of the spinal discs, nerves and cord have occurred. Cerebrovascular accidents, such as a stroke, have also been reported and that these have been estimated to occur in 1 in 2 million to 1 in 3.9 – 5.8 million cervical manipulations, about the same probability of stroke occurring from turning your head or having your hair washed in a salon (“beauty parlor stroke”). It cannot be said with any certainty that the specific treatment caused the stroke or aggravated an underlying, pre-existing condition or the treatment given was totally unrelated to the resulting stroke. 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 cervical adjustment or manipulation is extremely remote.

    I understand and I do not expect the Doctor to be able to anticipate all the potential risks or complications. There may be problems or complications that might arise from treatment and recommendations other than those noted. These other events or complications occur so rarely that it is not possible to anticipate and/or explain them all in advance of treatment.

    I wish to rely on the Doctor to exercise their best professional judgment during the course of the chiropractic examination and treatment, which the doctor feels is in my best interest, based upon the facts as then known at the time. I will immediately notify a member of the office staff of any unanticipated side effects or adverse reactions associated with treatment. I also understand that if I become concerned about any post-treatment discomfort or, if I should develop any new or unrelated symptoms, I should call the practice for immediate attention. I also understand that if from some reason I am unable to reach or contact the practice, that I should telephone my Primary Care Doctor or present myself to the nearest hospital emergency room.

    I understand that there are reasonable alternatives to treatment including, but not limited to: rest, home application of therapy, prescription or over-the-counter medication, exercise, non-treatment, treatment and evaluation by another provider and surgery. Each is associated with, their own benefits and risks. I have the right to request a referral to another provider for further evaluation, assessment and management of my presenting condition(s) at any time.

    CONSENT By affixing my signature, I acknowledge that I have read and understood the above consent and have had the opportunity to ask questions about its content and meaning, if so desired, which have been answered to my satisfaction. PRIOR TO MY SIGNING OF THIS CONSENT FORM.

    I, the undersigned, hereby request, consent to and authorize InMotion Spine Muscle Joint to conduct physical examinations, perform testing procedures are required, and administer treatment as deemed necessary or advisable for my presenting complaint(s) that are within the scope of the practice of chiropractic care. I attest that the information provided in regards to my, or my dependents current and past health history has been completed to the fullest extent and to the best of my knowledge and ability and does not contain false or misleading information, nor omission. I also certify that no guarantee or assurance has been made to me as to the results that may, be obtained from any treatment rendered.

    I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions which I seek examination and treatment for myself or my dependent.

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    I do hereby authorize and give my consent to InMotion Spine Muscle Joint to provide evaluation and treatment as needed and necessary to my minor child in my absence following initial consultation.

    My child will be accompanies by (check all that apply):

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