Lakeline Wellness Center
Field Services Registration

Informed Consent to Services
The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a “click” or “pop”, such as the noise when a knuckle is “cracked”, and you may feel movement of the joint. Light physical therapy such as manual release, stretching, or a mechanical muscle massager may also be used if warranted.
Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment.
Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as “rare”, about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered “rare”.
Other treatment options which could be considered for musculoskeletal pain include: Over-the-counter analgesics. Medical care, Hospitalization or Surgery .  Explanation of your options are a legal requirement for treatment.

Risk acknowledgement:  I have had the following unusual risks of my case explained to me.  I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and hereby give my full consent to treatment.  By clicking this form I acknowledge as an electronic signature that I do not present any extenuating risk factors including uncontrolled diabetes, current cancer treatment, uncontrolled hypertension, long term oral birth control usage, or smoking.