top of page

Chiropractic Consent

Please complete each of the fields by hitting the submit button in each section.

Thanks.  Scroll down for the next section.

Chiropractors employ various manually-applied treatment procedures when caring for patients, the most common being an adjustment.  A chiropractic adjustment involves the application of a quick, precise and usually painless force directed over a short distance to a specific body part.  Adjustments can be performed by hand, by hand-guided instruments, and with the use of specially designed equipment.  In addition to adjustments, chiropractors may use other treatment procedures to care for a patient, such as mobilization procedures, physiotherapy modalities, soft-tissue manipulation, nutritional recommendations, exercise and rehabilitative measures.  Neck and back pain are known to generally improve in time, however, recurrence is common.  It is also known that keeping a positive attitude and remaining physically active improves one's chance of recovery.

The beneficial effects associated with chiropractic treatment procedures include decreased pain, improved mobility and function, and reduced muscle spasm.  There are some conditions for which chiropractic care is contraindicated; other conditions may not respond to chiropractic treatment or perhaps worsen with chiropractic treatment.  In these cases, referral to another healthcare provider may be necessary or suggested by the chiropractor.

The body of evidence suggests that chiropractic care is generally safe; however, as with any form of treatment, some risks may be involved.  Listed below are summaries of both common and rare side-effects/complications reported to be associated with chiropractic care:



- Reactions most commonly reported are local soreness/discomfort (53%), headaches (12%), tiredness (11%), radiating discomfort (10%), dizziness, the vast majority of which resolve within 48 hours.


- Fractures or joint injuries in isolated cases with underlying physical defects, deformities or pathologies.

- Burns due to some physiotherapy procedures.

- Disc herniation

- Cauda Equina Syndrome (1 case in 100 million adjustments)

- Vertebrobasilar artery stroke (1 case per 400,000 to 1 million cervical spine adjustments [manipulations]).  A similar level of association for stroke is also found for patients under the age of 45 when consulting with a medical doctor; for those older than age 45, the level of association for stroke is higher when seeing a medical doctor than a chiropractic doctor.  Please indicate if you have a headache or neck pain that is the worst you have ever felt.

Alternate forms. of treatment that a patient may want to consider before undergoing chiropractic care include prescription and over-the-counter medications, surgical intervention, and non-treatment.  Listed below are summaries of concern with these alternative procedures:

- Long-term use or overuse of certain medications carry some risk of dependency; with other medications, long term use or overuse increases the risk of gastrointestinal bleeding.

- Surgical risks may include unsuccessful outcome, complications such as infection, pain, reactions to anesthesia, and prolonged recovery.

- Potential risks of refusing or neglecting care may result in increased pain, restricted motion, increased inflammation, and worsening condition.

Digital production of Palmer College of Chiropractic Informed Consent Form.


Have you ever had an adverse (i.e. bad) reaction to or following chiropractic care?
Are you sufferig from a headache or neck pain that is the worst you've ever felt or unlike any you've had?

Bone Weakness

Have you been diagnosed with osteoporosis?
Do you take corticosteroids (e.g. prednisone)?
Have you been diagnosed with a compression fracture(s) of the spine?
Have you ever been diagnosed with cancer?
Do you have any metal implants?

Vascular weakness

Do you take aspirin or other pain medication on a regular basis?
Do you take warfarin (coumadin),heparin, or othe similar "blood thinnes"?

Have you ever been diagnosed with any of the following disorders/diseases?

Rheumatoid arthritis
Giant cell arteritis (temporal)
Bachet's disease
Fibromuscular dysplasia
Reiter's syndrome, ankylosing spondylitis, or psoriatic arthritis
Osteogenesis impefecta
Ligament hypermobility (Marfan's/Ehlers-Danlos)
Medial cystic necrosis (cystic mucoid degeneration)

Spinal compromise or instability

Have you had spinal surgery?
Have you been diagnosed with spinal stenosis?
Have you been diagnosed with spondylolisthesis?

Have you had any of the following problems?

Sudden weakness in the arms or legs?
Numbness in the genital area?
Recent inability to urinate or lack of control when urinating?

I have read the previous information regarding risks of chiropractic care and my doctor has explained my risks (if any) to me and suggested alternatives when those risks exist.  I understand the purpose of my care and have been given an explanation of the treatment, the frequency of care, and alternatives to this care.  All of my questions have been answered to my satisfaction.  I agree to this care.


bottom of page