Healthcare Manipulations Form

HEALTHCARE MANIPULATIONS FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

Pre-Procedure Screening

Please check any that apply:

I am pregnant or may be pregnant
I take blood thinners (anticoagulants)
I have or have had cancer
I have heart disease or pacemaker
I have a recent fracture or severe osteoporosis

Description of Recommended Manipulations

Provider will perform manual manipulative therapy directed to joints and soft tissues for the purpose of restoring mobility, reducing pain, and improving function. Specific areas to be treated:

Risks, Benefits, and Alternatives

I understand the intended benefits of manipulative therapy include reduction of pain, improved joint mobility, increased function, and reduced need for medication. I acknowledge no guarantees have been made concerning outcomes.

I understand the potential risks include, but are not limited to: soreness or swelling, soft tissue injury, aggravation of pre-existing conditions, fracture, disc injury, nerve damage, stroke, and in rare cases permanent disability or death. I acknowledge these risks may occur even when the procedure is performed properly.

Reasonable alternatives to the proposed manipulations include: no treatment, medical management (medication), physical therapy without thrust techniques, surgical consultation, and other conservative measures. I have had the opportunity to ask questions and these have been answered to my satisfaction.

Consent and Authorization

By signing below I certify that I have read and understand this form, that the information I have provided is true and complete to the best of my knowledge, and that I consent to the specified manipulative procedures. I authorize the provider and staff to perform the agreed-upon procedures and any additional actions that are reasonably necessary during the course of treatment.

I understand I may withdraw this consent at any time except to the extent that action has already been taken in reliance on it. Withdrawal of consent shall be provided in writing.

I understand that the provider will use and disclose my protected health information for purposes of treatment, payment, and healthcare operations as necessary to provide care. I acknowledge receipt of the facility's privacy practices and understand my rights with respect to my health information.

Authorization Expiration Date:

Consent for Recording and Images: I consent to photography or video recording related to my treatment for clinical documentation

HIPAA Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices and consent to use and disclosure of my health information for treatment, payment, and healthcare operations.

Patient Statement

I attest that I have provided an accurate medical history to the best of my knowledge and that I have had the opportunity to discuss the proposed manipulations, risks, benefits, and alternatives with my provider. I consent to proceed with treatment.

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