Turtle Creek Wellness & Chiropractic

3102 Oak Lawn Ave. Suite #205 Dallas, TX 75219
(214) 521-6868

Patient Information

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If you are using insurance please fill out the following information. If self-pay move on to the emergency contact.
Patient Relationship to Insured: *

Emergency Contact

Chief Complaint / Symptoms

Which best describes your problem area *
Have you had this problem in the past *
Which best describes your sympotoms *
Have you ever had any of the following studies to your head, neck, mid-back, or low back? *

Electronic Consent & Signature

The Nature of chiropractic treatment: the doctor will use his heands or a mechanical devise in order to mobilize your spinal joints. You may feel a release or movement of that joint through it's physiological barrier to improve spinal joint motion. This release of motion often elcits an audible sound. Various ancillary procedures such as tempertaure therapy, electrical stimulation units, mechanical traction tables, etc may also be used to improve spinal joint functionality.
Possible Risks: As with all health care procedures, medications, or modalities, complications are possible following chiropractic mobilization. Complications may include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke couls occur upon severe injury to arteries of the neck. A minority of patients may notice soreness or stiffness after the first few days of treatment. The ancillary procedures could produce skin irritations, burns, or minor complications.
Probablity of Risks: The risks of complications due to chiropractic treatment are extremely rare and have been described as rare as complications arise from taking a single asprin tablet. The risk of cerebrovascular injury or stroke, has been studied an estimated to be at 1 in 1 million to one in 20 million, and can be further reduced by screening procedures. The probablity of adverse reaction to ancillary procedures is also considered to be extremely rare.
Risks of remaining untreated: Delay of treatment allows for adhesions, scar tissue and degenerative changes. These changes can irratate the central nervous sytem causing chronic pain cycles. It is proven delaying treatment can and will complicate the condition and make any furture rehabilitation more difficult.
Unusual Risks: I have had the following unusual risks of my case explained to me in aforementioned. I have read the explanation above concerning chiropractic treatment. I have fully evaluated the risks and benefits of undergoing treatment. I have had the opprotunity to read the above consent form in full. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.  
My consent is freely given. I understand I may reverse this consent at any time in writing, but any disclosures given in reliance on this prior consent will be permissible. *
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