To the patient: Please read the entire document prior to signing it. It is important that you understand the
information contained in this document. Please ask questions before you sign if there is anything that is

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will

use that procedure to treat you. I may use my hands (or a mechanical instrument) upon your
body in such a way as to move your joints. That may cause an audible "pop" or "click", many of
you have experienced this when "cracking" a knuckle. You may feel a sense of movement.

Analysis / Examination / Treatment
As part of the analysis, examination, and treatment, you are consenting to the following procedures:

As with any healthcare procedure, there are certain complications which may arise during manipulation and therapy. Iliesc complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, and therapy burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.
Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check during the initial intake review of history, examination, and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in a million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options.
Other treatment options for your condition may include:
• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatories, muscle relaxants and pain-killers

• Hospitalization
• Surgery
If you choose to use one of the above noted "other treatment" options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility and may lead to a degenerative process. Overtime this process may complicate treatment making it more difficult and less effective or result in a longer recovery process the longer it is postponed.