Balanced for Life: Chiropractic Initial Consultation

Balanced for Life: Chiropractic Initial Consultation

Chiropractic Initial Consultation FOrm Form Preview
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    All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. 

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  • History of Pathology













  • Consent

    At Balanced for Life, we aim to provide the highest quality care. Part of this care may involve cervical (neck) manipulation. We feel it is important that you are aware that as with any health care procedure there is some risk associated with cervical manipulation. The risk is currently estimated at 1 in 1,000,000 for stroke or stroke like symptoms. This is a rare and unpredictable event. Other risks that can be associated with spinal adjustments include disc injuries, rib fractures, sprains/strains or pre-existing conditions may be aggravated. We take every precaution to ensure that this risk is minimised through thorough testing, examination and the use of gentle and specific techniques. If you have any concerns, please let the chiropractor know.

    I acknowledge that I have been informed of the risks involved and understand that if at any time I have concerns they can be discussed with the chiropractor. I appreciate that I will receive the best care possible at Balanced for life but that results cannot be guaranteed. I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor seems necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date.

    Your information is private and confidential, however we may need to correspond with various third parties, including your GP, specialist or insurance company.

    Balanced for Life provides an appointment reminder service by email or Phone call and may also communicate with you by SMS and email from time to time, for the purposes of clinic announcements and patient education.

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