Adult New Patient Form

Office Use Only

Name:

D.O.B.

I.D.

Date:

Please take the time to complete all of our initial consultation information forms.

IT IS A LEGAL AND SAFETY REQUIREMENT THAT YOU ANSWER ALL OF THE FOLLOWING QUESTIONS

Likewise, we are concerned that occasionally patients may have a deteriorating or damaged disc in their lower spine. Have you experiences any of the following in the past 30-90 days?

Loss of bowel or bladder control

Yes

Loss of leg muscle size or numbness in the legs

Yes

Difficulty standing or progressive weakness in the legs

Yes

Shooting or sharp pain in the low back or legs when coughing or sneezing

Yes

Please note, We will have you sign in the office.

Patient Name

Date

Patient Signature

INFORMED CONSENT FOR CHIROPRACTIC CARE

When performed by a qualified Chiropractor, spinal manipulation is an effective and safe method of treatment for many painful conditions. There is however, risks associated with any treatment, and Dr Logan is required to inform you of these, even though there has never been a case in this clinic (other than post treatment muscle and joint soreness). Please read the following carefully and write down any questions you may have.

Scope of care:

Chiropractic care is focused on finding and correcting spinal problems that alter the normal spinal shape and movement. Spinal problems may affect the healthy function of the nerves and spinal cord and be detrimental to health. Chiropractors correct spinal problems using forces applied generally by hand or special drop piece tables. These forces made are called adjustments. Chiropractors may use various exercises, traction devices, shoe lifts or specifically prescribed orthotic devices to help the spinal corrections.

Chiropractic examinations require palpation of the spine and pelvic region. It may also require palpation of the sternum, cranial structures including intra-oral. There will be a chaperone present during examination and treatment in an open plan environment. Private consultation, examination and treatment can only be provided outside of office hours for an additional fee.

Treatment duration will be assessed and recommended at the initial consultation, and revisited each visit as needed, with further progress reviews done every 12 visits.

Medication:

It is common for patients to report changes in medical health conditions. However, changes in medications or management of medical conditions need to be done by your General Practitioner or Specialist. Chiropractors can not advise you as to your medical needs.

Risks of NOT undergoing care:

Spinal problems may get worse if untreated and may lead to progressive damage of the spinal discs, the spinal nerves, the spinal cord and affect general health.

Risks to patients:

All types of care and examinations have associated risk and it is important that a patient accepts these before undergoing examination and any care including adjustment, exercise and/or traction. Adjustments require forces to move skeletal bones and as such puts stress on blood vessels, bones, discs, nerves and soft tissue. The below are some of the more serious risks but it is not an exhaustive list:

A) RARE BUT SERIOUS RISKS: Damage to blood vessels, bones, discs or spinal cord may lead to death, stroke, paralysis or permanent injury.
B) MORE COMMON BUT LESS SERIOUS RISKS: Sprains, strains, rib fractures, bruising, inflammation and soreness.

I, (the undersigned) do not expect Dr Logan to be able to anticipate and explain all of the risks and complications, and I wish to rely on Dr Logan to exercise judgement during the course of treatment, which he feels at the time, based upon the facts then known, is in my best interest. I (the undersigned) also understand that results are not guaranteed.

Consent for x-rays:

x-rays are taken when indicated to access spinal biomechanics and the integrity of osseous and soft tissue structures.

Females only – Pregnancy Release:

X-rays can be hazardous to an unborn child. In signing below I consent to x-ray evaluation and certify that to the best of my knowledge I am not pregnant.

In signing below you acknowledge that you have been given opportunity to ask further questions about the spinal examination and spinal x-rays. I also intend this consent form to cover the entire course of treatment for my present condition, and for any other future condition(s). This consent can be withdrawn at any time.

I, the undersigned, hereby request and consent to any required x-rays and chiropractic treatment by Dr William Logan, and/or any other chiropractor working in this clinic authorised by Dr William Logan for myself or the child written below.

Please note, We will have you sign in the office.

Patient name:

Signature:

If applicable - Carer’s Name:

Signature:

Dr William Logan signature:

Date: