Consent to Treatment

I, the undersigned, do hereby consent to and authorize the performance of chiropractic services, including but not limited to, chiropractic adjustments, manipulations, physiotherapeutic modalities, diagnostic imaging, and other chiropractic procedures as deemed appropriate at Back Foundation Chiropractic.

Scope of Chiropractic Services

The scope of chiropractic care in the state of California includes, but is not limited to:

• Spinal Adjustments and Manipulations: Manual adjustments and manipulations to correct vertebral subluxations and other musculoskeletal issues.

• Extremity Adjustments: Adjustments to joints other than the spine, including the shoulders, hips, knees, and ankles.

• Physiotherapeutic Modalities: Application of therapies such as ultrasound, electrical stimulation, cryotherapy, heat therapy, and therapeutic exercises to aid in pain relief, muscle relaxation, and rehabilitation.

• Diagnostic Imaging: Ordering and interpretation of X-rays, MRIs, and other imaging studies to assist in the diagnosis of musculoskeletal conditions.

• Nutritional and Lifestyle Counseling: Guidance on diet, exercise, and lifestyle modifications to support overall health and wellness.

• Soft Tissue Therapies: Techniques including myofascial release, trigger point therapy, and massage to address muscle and connective tissue conditions.

Risks and Benefits of Chiropractic Care

I understand that chiropractic care, like all forms of healthcare, carries certain risks and benefits. Potential risks include, but are not limited to, soreness, muscle strain, sprains, disc injuries, fractures, and in rare cases, more serious complications such as stroke. Benefits of chiropractic care may include pain relief, improved mobility, reduced inflammation, and enhanced overall health.

I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise professional judgment during the course of care based on the facts then known.

Patient Acknowledgements

• Questions and Understanding: I acknowledge that I have had the opportunity to ask questions about the nature, purpose, and potential risks of the chiropractic care provided. I understand the information given to me and consent to the proposed treatment.

• No Guarantees: I understand that no guarantees have been made regarding the outcome of the treatment.

• Financial Responsibility: I agree to be financially responsible for the cost of all services rendered and understand that payment is due at the time of service unless other arrangements have been made.

• Cancellation Policy: I understand that appointments missed or canceled without 24-hour notice may incur a cancellation fee as per the office’s policy.

Acknowledgement and Consent

By signing below, I acknowledge that I have read and understood the information provided in this consent form. I agree to the treatment plan proposed by the chiropractor and give my consent for the provision of chiropractic care as outlined above.

Consent for Chiropractic Treatment of a Minor

I, the undersigned, am the parent or legal guardian of the above-named minor. I hereby authorize and give my consent to Back Foundation Chiropractic and associated chiropractors, to provide chiropractic treatment and care to my minor child.

I understand that chiropractic care may include but is not limited to adjustments, physiotherapeutic modalities, and other forms of care as deemed appropriate by the treating chiropractor.

I have been informed of the nature and purpose of chiropractic care, the procedures to be used, and the potential risks and benefits associated with such care. I acknowledge that no guarantee or assurance has been made regarding the outcome of the treatment.

I understand that I have the right to ask questions and discuss any concerns regarding the treatment plan for my minor child. I also understand that I may withdraw my consent at any time, but such withdrawal will not affect any treatment that has already been provided.

I also authorize Back Foundation Chiropractic Abrahams, PC to release any necessary health information related to the treatment of my minor child to third parties such as insurance companies for the purpose of processing claims.