Informed Consent to Chiropractic Treatment

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1600 Rymal Rd East Hamilton ON L8W 3P1 Ph: 905-692-4222 Fax: 905-692-0222 E-mail: info@hamiltonbackclinic.com Informed Consent to Chiropractic Treatment There are risks and possible risks with manual therapy techniques used by doctors of chiropractic. In particular you should note: A) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures. B) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in early stages of a stroke. In essence, there is a stroke in progress. However 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 upper cervical adjustment is extremely remote. C) There are rare reported cases of disc injuries following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment. D) There are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic. I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this consent. I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended Spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. Dated this day of, 20 Patient signature (Legal Guardian) Witness of signature Name (Please print) Name (Please print)

1600 Rymal Rd East Hamilton Ontario L8W 3P1 Ph: 905-692-4222 Fax: 905-692-0222 E-mail: info@hamitonbackclinc.com Informed Consent for Acupuncture I hereby request and consent to the performance of acupuncture and other procedures related to acupuncture if necessary including needling, moxabustion, cupping, guasha, laser, electro acupuncture and other techniques within the scope of practice of acupuncturists. These procedures may be performed by the acupuncturist or another duly authorized person in the clinic. I have had the opportunity to discuss with the acupuncturist and /or with other office or clinic personnel the nature and purpose of acupuncture care and other procedures. I understand that results are not guaranteed. I have been advised that all insertion needles are pre-sterilized and disposable. I further understand and am informed that, as with all health care, the practice of acupuncture posses slight risks from treatment, including but not limited to temporary soreness, bruising, blistering, nausea, fainting, bleeding, lung injury, infection and shock. I do not expect acupuncturists to be able to anticipate and explain all risks and complications and I wish to rely on the acupuncturist to exercise judgment during the course of the procedures which the acupuncturist feels at the time, based upon facts then known, are in my best interest. I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above named procedure(s). I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Dated this day of,20 Patient Signature Witness Name: (please print) Name: (please print)

Hamilton Back Clinic p.c. 1600 Rymal Road East, Hamilton, ON L8J 2R5 Payment Schedule Chiropractic / Acupuncture Initial Visit (Standard) $75 Standard Visit (Standard) $45 Laser Therapy $45 Physiotherapy Initial Visit $82 Follow Up Visit $62 ** I understand payment is due on the same day that I have been treated. Patient Signature: / Date: Missed Appointments If you must cancel an appointment, we require that you notify us 6 hours prior to your scheduled appointment. There will be a $15.00 fee for missed appointment. Revised September 19, 2011

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