Terms of Acceptance/Informed Consent
When we accept you as a patient it’s important that you understand the objectives of our care. Chiropractors provide a unique service that other healthcare providers do not offer. Chiropractors specialize in the location and correction of vertebral subluxations for the purpose of improving the health and function of your spine and nervous system. A vertebral subluxation is a misalignment or distortion of your spinal column and/or related structures that can affect your health and overall body functioning. Chiropractors spend years studying how to locate and correct this destructive condition. The correction is performed using specialized techniques called “chiropractic or spinal adjustments” over a period of time. When your spine is free of the nerve and musculoskeletal stress caused by subluxations your body can function more efficiently and your body’s natural ability to heal can work more optimally. It is not our objective to medically diagnose or treat any disease, symptom or condition. If you desire diagnosis or treatment for a specific symptom or treatment of a specific symptom, disease, or condition or advice on taking or stopping medications, we recommend you consult a healthcare provider who specializes in that area. If we discover unusual findings in the course of our chiropractic examination(s) we will let you know of them. You may then decide whether you wish to investigate further and discuss your healthcare options with other health professionals. Chiropractic, like all forms of health care, while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal. In very rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the extremely rare complications associated with spinal manipulation, occurring at a rate between one per one million to one per twelve million cervical spine (neck) adjustments is vertebral artery injury. This very rare occurrence could lead to stroke. Prior to receiving chiropractic care from Optimal Wellness for Life Chiropractic Center, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a recommended plan of care prior to beginning care. The purpose of chiropractic care is not to treat disease or conditions, nor to suppress symptoms, nor to perform surgery or prescribe medications but rather to improve the health and function of your spine and nerve system to help your body function at it’s optimum health and healing potential. It is our sole objective to improve and maintain the health and normal function of your spine and nerve system to the maximum degree possible for you.
Additional Consent to Treatment of Minor
I, the undersigned, being the parent and/or legal guardian of the above-referenced minor(s) consent to and request that he/she be examined, evaluated and treated at this office within the scope of Doctor of Chiropractic (D.C.) services rendered which may include but are not limited to x-rays, examinations, evaluations, diagnoses, and treatment as chiropractically indicated and/or are recommended or directed by our Doctor(s) of Chiropractic or other qualified staff of Optimal Wellness for Life Chiropractic Center
This consent shall be valid from this date forward until this applicable case is resolved or withdrawn by the undersigned. I, the undersigned, understand that I am responsible for, and agree to pay for any and all outstanding monies due for services rendered hereunder and understand that I must notify Optimal Wellness for Life Chiropractic Center IN WRITING of my intent to withdraw my consent.