Healthcare Patient Consent for Chiropractic

HEALTHCARE PATIENT CONSENT FOR CHIROPRACTIC

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Are you pregnant or suspect you may be pregnant?

Do you have a pacemaker or other implanted medical device?

Description of Proposed Chiropractic Care

Proposed care may include spinal and extremity manipulation (adjustments), mobilization, soft tissue therapy, therapeutic exercise, electrical modalities, traction and diagnostic imaging as indicated. The proposed primary interventions specific to this episode are described below.

Risks, Benefits and Alternatives

I acknowledge that no guarantees have been made to me concerning the results of treatment. I have been informed and understand that the nature of chiropractic care and spinal manipulation includes, but is not limited to, the following potential risks and complications, which are rare but possible: increased pain or stiffness, soft tissue injury, sprain/strain, fracture (rare; increased risk with osteoporosis or other bone-weakening conditions), neurologic injury including nerve irritation or injury, stroke or arterial injury associated with cervical manipulation (extremely rare), dizziness, nausea, and adverse reaction to modalities or topical substances.

Alternative treatment options may include referral for medical management, physical therapy, injections, diagnostic testing, or no treatment. I have had the opportunity to ask questions about the nature and purpose of the proposed procedures, the potential risks and benefits, and the alternatives including the likely outcomes if treatment is not undertaken.

Consent and Authorizations

By signing below I certify that I have read and fully understand the information presented above. I consent to the performance of chiropractic care, diagnostic procedures and any ancillary services deemed necessary by my treating clinician. I consent to spinal and extremity manipulation and to other procedures described in Planned Treatments / Procedures. I understand I may refuse any specific procedure at any time.

I authorize the release of my protected health information to my insurer and to other health care providers as required for treatment, payment and health care operations. I authorize the provider to obtain, use and disclose medical records and diagnostic information necessary to process claims and coordinate care. This authorization expires on:

I understand that I am financially responsible for charges not covered by my insurer, including co-payments, deductibles and services denied by the insurer. I authorize assignment of benefits to the treating provider and authorize payment directly to the provider for covered services. I agree that a photocopy or electronic copy of this document has the same force and effect as the original.

  I acknowledge receipt of the clinic's privacy practices and understand how my protected health information will be used and disclosed in accordance with applicable law.

  I consent to necessary diagnostic imaging (X-ray, CT, MRI) and clinical photography for assessment, treatment planning and medical records.

  I authorize emergency medical care to be provided if, in the judgment of the clinician, it is needed during my course of treatment.

Patient Rights

I understand that my consent is voluntary. I have the right to withdraw consent at any time by providing a written statement to the clinic, except to the extent that action has already been taken in reliance on this consent. Refusal to consent will not result in criminal or civil liability, but could result in the provider declining to provide non-emergent care.

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