Informed Consent for Treatment Form

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Content to be included:
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Simplest as two separate documents:

• Consent to be examined...

1. in the new patient document.
2. Only one sentence, above the patient signature.

• Informed consent to treatment plan...

1. Plan made by doctor.
2. Pricing and payment plan made by registrar.
3. Consent with payment made by patient.

~~~~~~~~~~~~~In your new patient forms~~~~~~~~~~~~~~~~~~

INFORMED CONSENT FOR EXAMINATION

I request and allow the doctor and the staff here to examine me. I understand there is mild risk of increased pain or soreness during my examination.

Signed ~ Pati Ent
Date~ March 2, 2011


~~~~~~~~~~~~~~~~~~~~on your letterhead~~~~~~~~~~~~~~~~~~~~~~~~`

YOUR PERSONALIZED PLAN

Goal for Treatment: ~alleviate backache after a fall Feb 22~
Problem: (Diagnosis): ~back ache from fall~
Expectation (Prognosis): ~good for full recovery in six weeks~

Recommended Treatment Schedule: ~2x weekly for 6 weeks, then re-evaluate~

Chiropractic Care: ~three spinal regions & leg~
Therapy Modalities: ~ yes, each visit after chiropractic~

risks: soreness, fractures, disc injuries, strokes, dislocation and sprains
alternatives: physical therapy only, medication, acupuncture, waiting.

Other notes: ~osteoporosis increases risk of fracture~

INFORMED CONSENT FOR TREATMENT

I understand the risks names above. I request and allow the doctor and the staff here to examine and treat me as described above.

Signed ~ Pati Ent
Date~ March 2, 2011

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Cautions on this form:

You need to add something to this if the patient asks specific questions, or has increased risk, say for osteoporosis or prior spinal surgery. Leave margin space for this.




All the best to you and yours.
Gary Shannon