Notice of Informed Consent
California Code of Regulations, Title 16, Div. 4, Article 2, Section 319.1 requires your acknowledgement of proposed risks relating to care at this office in the form of an informed consent by signature on intake form.
The procedures used in this office require interactive participation defined as skin surface reflexes, hard and soft tissue manipulation. Soft tissues manipulation sites are on the torso, pelvis, and face. I am active during the treatment, moving quickly from one place on the body to another, and for some individuals sensitive areas may be brushed, touched or pushed or pressured. Kindly be assured that there is no intention ever to violate personal boundaries, yet these vary considerably from one person to another. If ever you feel uncomfortable at any time during a treatment session, please do not hesitate to speak up and ask me to pause so I hear and understand what you need.
Hard tissue manipulation (chiropractic adjustments) may be incorporated infrequently in the form of spinal, cranial and or extremity manipulation. When these manipulation procedures are employed you will be verbally notified. As a general rule, manipulation steps are incorporated to stimulate reflexes within bony and adjacent soft tissue structures that stimulate involved neural pathways. i.e. simply stated act as resetting a circuit breaker.
Soft tissue manipulation steps are a combination of rubbing, stretching, and pinching type activities. Steps that are known to cause brief physical discomfort include stimulation of internal jaw muscles. This step is frequently employed on every visit. A clean finger cot is always used for this procedure. If you have a latex sensitivity please let me know
Signature ____________________________________________ Date: _______________
I have verbally reviewed consent with patient. _______________ Date: _______________
It is the goal of this office to provide health care in a cost effective and efficient manner. To accomplish this, we utilize minimal staff and ancillary services. If you miss an appointment or fail to give us appropriate cancellation notice of 48 hours, there may be a fee, typically half the session charge. It is your responsibility to call and reschedule as well as to schedule preventive /follow up visit(s), commonly every 4-6 months.