Below see some entries in our recent Consent Form Contest



Congratulations for having chosen the safest and most natural health care program ever conceived: Chiropractic.

This painless, logical, and effective approach to health has been serving everyday people for over 100 years. It is licensed in every state, and in many countries as well. Chiropractic has the least chance of side effects of any other type of health care. Mild headaches and muscles soreness may sometimes occur.

Let’s look at a few statistics about possible serious side effects:

The #1 cause of death in the US is from correctly and incorrectly prescribed pharmaceutical drugs. (CDC, FDA, NIH sites, also Gary Null: Death By Medicine)

Stroke is one of the most common causes of death in the US. With people going to doctors all the time it is probable that many will have had a recent doctor visit. But causation is another matter entirely.

There is no absolutely known material risk of chiropractic care being greater than risks from medical treatment. In fact, when all the factors are taken together, deaths and injuries from a combination of medical mistakes and intentional drugs dwarf any injuries from chiropractic.

Risk of stroke from chiropractic? Virtually zero chance of stroke from chiropractic. The largest study ever done – the 2008 study in Canada – – looking at 12 million people over 9 years, showed that 53% of strokes had visited their MD within 30 days prior, while only 4% had visited their DC. No evidence of excess risk of stroke associated with chiropractic care.

In 2001 the Canadian Medical Association Journal found there is only a one-in-5.85-million risk that a cervical manipulation from an MD, PT, or DC would be followed by a stroke. Author David Cassidy, a professor of epidemiology at the University of Toronto said patients had already damaged the artery before seeking help from either a medical doctor or a chiropractor, and then the stroke occurred after the visit.

Speaking of risks associated with chiropractic, we should look also at the risk associated with NOT GETTING adjusted. This risk was one of the 4 components of risk in the Association of Chiropractic Colleges guidelines on informed consent in 2008. Disc degeneration, loss of mobility, loss of overall tone, decreased quality of life – these are real risks of the untreated spine as time goes by.

I fully understand these risks, the doctor has explained them to me and I consent to chiropractic care.

________________________ ____________________ ____________________
Sign print date



Doctors of Chiropractic who use manual therapy techniques are required to advise patients that there are or may be some risks associated with such treatment. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms, rib fractures or muscle and ligament strains or sprains as a result of manual therapy techniques:

b) There are reported cases of stroke associated with many common neck movements including adjustments of the upper cervical spine. Present medical and scientific evidence does not establish a definite cause and effect relationship between upper cervical spine adjustment and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently. However, you are being warned of this possible association because stroke sometimes causes serious neurological impairment, and may on rare occasion result in injuries including paralysis. The possibly of such injuries resulting from upper cervical spinal adjustment is extremely remote;

c) There is rare reported cases of disc injuries following cervical and lumbar spinal adjustments or chiropractic treatment.
Chiropractic treatment, including spinal adjustment, has been the subject of government reports and multi-disciplinary studies conducted over many years and has demonstrated to be effective treatment for many neck and back conditions involving pain, numbness, muscle spam, loss of mobility, headaches and other similar symptoms. Chiropractic care contributes to your overall well being. The risk of injuries or complications from chiropractic treatment os substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same treatments.

I acknowledge I have discussed, or have had the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the contents of this Consent.

I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal adjustment. 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 _________________________________________ Name:___________________________________
(Please print)


In accordance with California law, this notice is to inform you, as a patient of this office the risks of undergoing chiropractic care. The procedures that will be performed in the course of your care will consist of chiropractic adjustments using manual and instrumental techniques. The risk of care could include possible fracture of ribs (if you have an unusually low bone density). This risk will, of course, be evaluated before your care begins via x-ray examination and thorough history. Another risk from a chiropractic adjustment is the risk of stroke. This risk has been determined to be a risk of approximately 1 in 5.85 million. This risk will also be evaluated prior to the onset of your care to see if you have any predisposing factors for a stroke. There is also a risk of increased pain during the healing phase of your care. As your body begins be restored to normal health, there may be some periods of time when you will feel symptoms that had previously been gone. Understand that this is normal and indicates healing, as such you may also risk restored health and wellness.

The risks of not getting your prescribed treatment can include disc and spine degeneration, loss of mobility, loss of function of organs or cells that do not have nerve supply restored to them and loss of muscle tone.

My signature below signifies that the risks of chiropractic care have been explained to me verbally and in the above written statement.

________________________________________ ___________________
Signature of patient/guardian Date


Informed Consent

There are reported cases of stroke associated with visits to medical doctors and doctors of chiropractic. Research and scientific evidence does not establish a cause-and-effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and doctors of chiropractic when they are in the early stages of a stroke. In essence, there is a stroke already in progress.

However, you are being informed of this reported association because a stroke may cause serious neurological impairment or death. The possibility of such consequences occurring in association with cervical (neck) adjustments is extremely remote.

To help put this in perspective, one finds a 100 times greater risk of dying from general anasthesia; 160-400 times greater risk of dying from the use of NSAIDs (non-steroidal anti-inflammatory drugs); 700 times greater risk of dying from lumbar spinal surgery; and 1,000-10,000 times greater risk of dying from traditional gallbladder surgery.

I have read the foregoing information and a satisfactory explanation of the foregoing risks has been provided by the treating doctor. I consent voluntarily to proceed with care provided by ___________________ that may include cervical (neck) adjustments.

Print __________________________ Signature

patients name

Sign ___________________________