• Schantz Chiropractic, P.C.

    ACKNOWLEDGEMENT OF INFORMED CONSENT

  • To the patient: Please read this 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 unclear.

    The nature of the chiropractic adjustment. The primary treatment I use as a Doctor of Chiropractic is spinal manipulation or chiropractic adjustments. 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,” much as you have experienced when you “crack” you knuckles. You may feel a sense of movement.

    The material risks inherent in chiropractic adjustment. All healthcare procedures carry benefits & risks. Despite our best efforts to minimize risk, possibilities exist that a complication may occur. Most complications are temporary soreness, stiffness, spasm or increase in symptoms. Serious complications are rare and may include, but not limited to disk injury, fracture, burn from heat or electrical devices or injury to an artery in the neck causing or contributing to stroke. 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 for during the taking of your history and during examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

    Other treatment options, outside the scope of chiropractic. Treatment options for your condition may include: Prescription & over-the-counter drugs such as anti-inflammatories, muscle relaxants and opioids. Injections into muscles, joints or the spine. Spinal laminectomy, spinal fusion, artificial disk or joint replacement surgeries. Be aware that there are risks and benefits of these treatment options and you may wish to discuss these with a nurse, pharmacist, surgeon or physician.

    The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions, chronic pain and disability. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
  • Date Format: MM slash DD slash YYYY