555 South Schuyler Ave #280 Kankakee, IL 60901 815-670-0245

1st Step Chiropractic, S.C. 4519 Highcrest Road Rockford, IL 61107 815-398-4500 555 South Schuyler Ave #280 Kankakee, IL 60901 815-670-0245

Terms Of Acceptance & Informed Consent When a person seeks chiropractic health care and we accept a person for such care, it is essential for both to be working towards the same objective. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the body’s ability to function correctly. Our method is specific adjusting to correct vertebral subluxation.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Benefits and Risks: It is important for you to understand the potential benefits of an adjustment which include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. With all health care approaches, results are not guaranteed, and there is no promise to cure. And as with all types of health care interventions, there are some risks to care including but not limited to: muscle soreness or spasm, aggravating and/or temporary increase in symptoms, and lack of improvement of symptoms. A word on the risk of stroke: the chiropractic association with stroke is exceedingly rare to the point of being a logical fallacy (estimated one in one million to one in two million cervical adjustments). The NUCCA procedure performed in our office does not involve any twisting manipulations and is considered one of the safest types of chiropractic care. Options: Finally, it is important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you may have tried many of these approaches already, including but not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. You may seek second opinions and secure other opinions regarding your health care.

I have read and fully understand the above statements.

Signed ______

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis. Signed ______Date______