Patient Information/Auto Accident Details

What was the date of your accident? *

What was the make and model of the car you traveling in? *

What was the make and model of the other car? *

Were you the: *

Driver	Front seat passenger
Rear seat driver side passenger	Rear seat passenger side passenger

Did you have your seat belt on at the time of the accident? *

Yes

No

Did airbags deploy in your vehicle? *

Yes

No

Were any of the windows broken on your vehicle including the front or rear windshield? *

Yes

No

Did airbags deploy in the other vehicle? *

Yes

No

Not Sure

Were police called to the scene? *

Yes

No

Did you go to the hospital by ambulance? *

Yes

No

Did anyone from either vehicle go the hospital by ambulance? *

Yes

No

Have you gone the hospital or any health care provider for the accident at all? *

Yes

No

If yes, when and where did you go? *

Do you have an estimate on the amount of damage done to your vehicle? Total loss, etc., *

Patient First Name *

Patient Last Name *

Patient Address *

City *

State *

Zip *

Patient Phone Number *

Patient Date of Birth *

Social Security Number *

Patient Email Address *

Do you have an attorney? *

Yes

No

If yes, please provide name and phone number: *

Describe how the accident happened: What time of day? How was the weather? Where did the accident take place? *

Electronic Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his hands or a mechanical devise in order to release motion through the spinal joints or extremity joints. You may feel movment of the joint. This movement releases the joint through it's functional range of motion. You may hear an audible sound as this release occurs. Various ancillary procedures may be used as well, such as, hot or cold packs, electric muscle stimulators, mechanical traction tables, etc,.

Possible risks: As with all health care procedures there are possible risks. Complications following a chiropractic mobilization of the spinal joints or extremity joint could include: fractures of bones, muscular strain, ligament sprain, dislocations of joints, or injuries to the intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occurupon 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 irratation, burns, or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as rare, about as often as complications arise from taking a single asprin tablet. The risk of cerebrovascular injury or sttroke has been studied and has been estimated at 1 in one million to 1 in 20 million, which can be further reduced by screening procedures. The probablity of adverse reaction to ancillary procedures is also considered rare.

Risks of remaining untreated: delay of treatment allows formation of inflammation, scar tissue, adhesions and other degenerative changes. these changes can further reduce skeletal mobility, and induce the central nervous system to elicit the formation of pain cycles. It is quite possible that delay in treatment will complicate the condition and make future rehabilitation more difficult.

Unusual risks: I have read the aforementioned unusual risks and the nature of chiropractic treatment. I have had the opprotunity to read the aforementioned unusual risks and have fully evaluated the risks and benefits of undergoing chiropractic treatment. I freely decide to undergo the recommended chiropractic treatment and hereby give my full consent to chiropraic treatment.

My consent is freely given. I understand I may reverse this consent in writing at any time, but my disclosures given in reliance on the prior will be permissible. *

I consent & agree to the terms above

I do not consent