Informed Consent to Chiropractic Treatment
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures
including various modes of physical therapy, and if necessary, diagnostic imaging on me (or for the patient named
below, for whom I am legally responsible:______________________) by the chiropractic doctor and/or anyone working
in this office authorized by the chiropractic doctor. I further understand that such chiropractic services may be
performed by the Doctors of Power Within Chiropractic and/or other licensed Doctors of Chiropractic who may treat me
now or in the future at this office. I have had an opportunity to discuss with the doctor and/or with other office or clinic
personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not
guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of
chiropractic carries some risks to treatment; including but not limited to: fractures, disc injuries, strokes (CVA),
dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications.
Further, I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels are
in my best interests at the time, based upon the facts then known. I have read, or have had read to me, the above
consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the
treatment recommended by my doctor. I intend this consent form to cover the entire course of treatment for my
present condition(s) and for any condition(s) for which I seek treatment at this facility.
To be completed by the patient:
To be completed by the patient’s representative, if necessary, (e.g. if the
patient is a minor or is physically or mentally incapacitated)
_______________________________
Print Patient’s Name
__________________________________
Print Name of Representative
_______________________________
Signature of Patient
___________________________________
Signature of Representative
______________________________
Date
__________________________________
Date
_______________________________
Dr. Signature
_________________________________
Date
I have read and completed all of the information above and have completed the above answers. I certify this
information is true and correct to the best of my knowledge. I will notify the practice of any changes in my health status,
my child(ren)’s health status, or the above information.
Privacy Statement Acknowledgement
I acknowledge Power Within Chiropractic has provided its Notice of Privacy Practices, either posted or an individual
copy, which provides a detailed description of the uses and disclosures allowed regarding my child’s protected health
information. If I desire, a copy of the Notice of Privacy Practices is available for me to keep. If revisions are made, I
understand that it is my responsibility to request a revised copy.
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Accompanying Minors
Please list anyone other than the child(ren)’s biological mother or biological father who may be accompanying the
child(ren) to appointments. This may include siblings over the age of 18, babysitters, step parents, grandparents,
neighbors, friends of the family, etc… I understand that only my child(ren)’s biological mother and father and those
listed below will have the authority to authorize treatment. I also authorize chiropractic treatment of my child age
_______, in my absence. Authorized individuals include (please print name and relationship):
_______________________________________
Name
_______________________________________
Name
_______________________________________
Relationship
_______________________________________
Relationship
**Please inform the above listed individuals to bring photo identification to appointments.**
**If the minor is unaccompanied by an adult for their appointment, the minor needs to be dropped off and picked up in
a timely manner. It is the policy of Power Within Chiropractic that unaccompanied minors wait in the waiting room for
no more than 10 minutes prior to/after their appointment time.
Unlisted individuals may obtain treatment for your child(ren) in the case of an emergency. In that case, an attempt to
contact you by phone will be made. This authorization will remain in effect until those designated above have their
consent revoked in writing.
Minors Scheduling Appointments
I do hereby authorize the following individuals (must be over the age of 18), or children listed, to schedule appointments.
_______________________________________
Name
_______________________________________
Name
_______________________________________
Relationship
_______________________________________
Relationship
Release Of Information
I give permission to Power Within Chiropractic to VERBALLY discuss my medical information (including appointment
schedules, symptoms, diagnosis, medications, treatment options, lab/test results) or payment information with the
following individuals involved in my care. This does not allow these individuals to obtain copies of my medical record.
_______________________________________
Name
_______________________________________
Name
_______________________________________
Relationship
_______________________________________
Relationship
_______________________________________
Signature of Patient
_______________________________________
Date