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Throm Informed Consent THROM HEALTH AND WELLNESS Informed Consent to Chiropractic Treatment Summary of Risks: “Chiropractic is widely recognized as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal complaints. Although chiropractic has an excellent safety record, no health treatment is completely free of potential adverse effects. The risks associated with chiropractic, however, are very small. Many patients feel immediate relief following chiropractic treatment, but some may experience mild soreness or aching, just as they do after some forms of exercise. Current literature shows that minor discomfort or soreness following spinal manipulation typically fades within 24 hours.” - American Chiropractic Association (ACA) Website Specific Risks of Treatment: 1. Generalized Soreness: Chiropractic adjustments and trigger point therapy are occasionally associated with post-treatment soreness. Please let your doctor know if you encounter any soreness. Your doctor may provide at-home icing, heating, stretching, or other instructions; or modify your treatment plan to minimize post-treatment soreness. 2. Soft Tissue Injury: Chiropractic treatment and trigger point therapy are rarely associated with soft tissue injuries such as mild sprains, strains, or bruises. Please let your doctor know if you encounter any of these as they may modify your treatment recommendations. 3. Rib Injury/Fracture: Manual adjustments to the thoracic spine may result in rib injuries on rare occasions, most commonly in patients with low bone density. If you or the doctor feel you are at risk based your health history, x-rays may be taken of the thoracic spine and rib region to assess bone density. Patients with low density may opt for lower-force instrument adjustments (Activator Technique). 4. Stroke: Manual adjustments to the cervical spine are extremely safe; however, there have been reports of high-velocity neck adjustments associated with vertebral artery dissection (V.A.D.), a certain type of stroke. Current research suggests this type of stroke typically occurs spontaneously with everyday motions of the neck. The most common prodromal symptoms of V.A.D. are severe neck pain and headache that leads them to seek professional care by a chiropractor or other healthcare provider, but that treatment is not the cause of the injury. “The best evidence indicates that the incidence of artery injuries associated with high-velocity upper neck manipulation is extremely rare – about 1 case in 5.85 million manipulations” (American Chiropractic Association). Orthopedic tests can be performed before treatment to determine if there is significant risk to justify lower-force instrument adjustments (Activator Technique) on patients with increased risk of thromboembolism or arterial dissection. Page 1 of 2 THROM HEALTH AND WELLNESS Notice of Privacy Practices We are dedicated to maintaining the privacy of your health information and we are required by federal and state laws to do so. These laws also require that our patients are provided with a notice of our privacy practices and inform you of your rights with regards to your health information. This Privacy Notice is effective as of August 1, 2013 and will remain in effect until replaced or amended. 1. Changes to Notice: We reserve the right to make changes to the following privacy practices at any time in order to maintain compliant with state and federal regulations. Before any significant changes are made to our clinic policies, we will alter this Notice, and have the revised Notice available at your request. These changes may be applicable to health information created or received by us prior to the date aforementioned changes are made. 2. Permitted Uses and Disclosures of Your Health Information: a. Treatment, Payment, and Healthcare Operations: i. Treatment: We may use or disclose your health information to other healthcare providers that are concurrently providing treatment to you. ii. Payment: We may use and disclose your health information to obtain payment for services provided to you. iii. Healthcare Operations: We may use and disclose your health information while performing healthcare operations including quality assessment and improvement activities and other business operations. 3. Authorizations: a. Unless we are given written authorization by you, we are unable to use or disclose your health information for any reason except those permitted by this Notice. We may disclose your health information to a family member, friend, or other party to help with your healthcare or with payment for your healthcare only if authorized to do so. You may revoke authorization by submitting a written notification to the clinic at any time. b. In the event of an emergency, or your incapacity, we will disclose health information based on our professional judgment; disclosing only information that is directly relevant to the individual’s involvement in your healthcare 4. Other Uses and Disclosures Required by Law: a. We are required by law to use or disclose your health information in certain circumstances i. Public Health Reasons – disease reporting, etc. ii. Patient and Third-Party Protection – if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or other crimes. Only as permitted by law we may disclose your health information in order to avert a serious threat to the health and safety of yourself or others. Page 2 of 2 .
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