Qualls Comprehensive Chiropractic, Inc.

Informed Consent

The nature of the chiropractic manipulation: I will use my hands or an instrument to move the joints of your body; this may result in an audible "pop" or "click".

The material risks inherant in an adjustment: As with any healthcare procedure, there are certain complications that may arise during a chiropractic manipulation.  This may include: strains, dislocations, fractures, disc injuries and stroke.  This list is not all inclusive.

The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones.  The other complications are considered rare.  One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher.  Even so, we employe tests during our examination to identify if you may be susceptible to that kind of injury.

Ancillary treatments recommended: __________________________________________________
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Risks involved with the recommended ancillary treatments: ______________________________
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Other treatment options for your condition include: Medical care with prescription drugs, self management with over-the-counter medication, rest, and/or surgery.  There are material risks inherent in each of these options including, but not limited to: addiction to medication, side effects of medication, improper self dosages and surgical risks including complications from the procedure and the anesthesia.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment.  I have discussed it with the doctor and have had my questions answered to my satisfaction.  By signing below I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended.  Having been informed of the risks, I hereby give my consent to treatment.

Patient Printed Name: _______________________________  Date: _______________________

Patient Signature: ___________________________________  Dr. _________________________

The patient had the following questions and was supplied the following answers:

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