Consent to Chiropractic Treatment
I consent to evaluation and chiropractic care provided by Back Foundation Chiropractic Abrahams, PC and Dr. Robert Abrahams, D.C., as clinically appropriate for my condition and within the lawful scope of chiropractic practice in California.

Nature and Purpose of Chiropractic Care
Chiropractic care may include examination, chiropractic adjustments or manipulation of the spine and other joints, treatment of related muscles and connective tissues, therapeutic exercise, physical therapy techniques or modalities, soft-tissue procedures, lifestyle or nutritional guidance related to chiropractic care, and diagnostic studies or referrals when clinically indicated.

The specific procedures recommended for me will depend upon my history, examination findings, diagnosis, response to care, and clinical circumstances.

Potential Benefits
The purpose of chiropractic care may include reducing pain or discomfort, improving joint motion and physical function, improving mobility, and helping me return to or maintain normal activities.

I understand that individual responses to care vary and that no particular result can be guaranteed.

Material Risks and Possible Complications
I understand that chiropractic care, like other healthcare procedures, involves risks. Depending upon the procedure and my individual condition, risks may include temporary soreness or increased discomfort, muscle or ligament strain or sprain, aggravation of an existing condition, disc injury, fracture, or other injury.

Certain procedures involving manipulation of the neck may also carry rare but potentially serious risks, including injury to arteries of the neck, neurological injury, and stroke.

The material risks of the care specifically proposed for me will be discussed with me verbally and in writing before that care is provided.

Alternatives
I understand that reasonable alternatives to chiropractic care may include receiving no treatment, modifying or delaying treatment, self-care, exercise or rehabilitation, medication or medical management by another healthcare professional, physical therapy, specialist evaluation, diagnostic testing, or other appropriate healthcare options depending upon my condition.

I understand that declining or delaying recommended care may result in persistence or worsening of symptoms or may delay diagnosis or recovery, depending upon the condition involved.

Questions and Voluntary Consent
I acknowledge that I have been informed of the nature and purpose of the chiropractic care proposed for me and have had the opportunity to ask questions about its potential benefits, material risks, and reasonable alternatives.

My questions have been answered to my satisfaction. I understand that I may ask additional questions at any time and may decline a particular procedure or withdraw my consent to future care before that care is provided.

I understand that no guarantee or assurance has been made regarding the results of chiropractic care.

Patient Acknowledgment and Consent
By signing below, I acknowledge that I have read and understood this Consent to Chiropractic Treatment and that the nature and purpose of the proposed care, its material risks, and reasonable alternatives have been discussed with me.

I voluntarily consent to the chiropractic evaluation and care discussed with me and recommended by Dr. Robert Abrahams, D.C.

Patient Name: ______________________________________________

Patient Signature: ___________________________________________ Date: _______________

Dr. Robert Abrahams, D.C. — Verbal informed-consent discussion completed

Initials/Signature: __________________________________________ Date: _______________

Additional Consent if the Patient Is a Minor
If the patient is a minor and consent from a parent, legal guardian, or other legally authorized representative is required, I represent that I am legally authorized to consent to healthcare on the minor patient’s behalf.

I authorize Back Foundation Chiropractic Abrahams, PC and Dr. Robert Abrahams, D.C. to evaluate and provide chiropractic care to the minor as clinically appropriate.

I acknowledge that I have been informed of the nature and purpose of the proposed care and have had the opportunity to discuss its potential benefits, material risks, and reasonable alternatives. I understand that no guarantee or assurance has been made regarding the outcome of treatment.

I understand that I may ask questions regarding the minor patient’s treatment and may withdraw consent for future care, subject to applicable law.

Minor Patient Name: ___________________________________________

Parent/Legal Representative Name: _______________________________

Signature: ____________________________________ Date: _______________

Relationship to Patient: _______________________________________