I understand that the following procedures may be necessary for the successful treatment of myself, or my above named child, or ward. I further understand that upon my request, the doctor will explain any procedure before applying it. I also certify that no guarantee or assurance has been made as to the result that may be obtained.

The Nature of applied treatments at our facility:The doctors and/or therapists at this facility will use any means necessary such as spinal manipulation, massage, intersegmental traction, hot packs, cold packs, stretching, soft tissue mobilization, traction of a particular joint or body part, and therapeutic exercises to help you the patient. Additionally, there may also be the usage of electrical modalities such as interferential stimulation or ultrasound to help your condition. Vitamins, herbs, and homeopathic remedies may also be recommended. There may be recommendations to other specialists for your condition.

The Material risks inherent to the above therapy: As with any health care procedure there are certain complications which could arise during any of the treatment listed above. While complications are uncommon, they include but are not limited to the following: fractures, disc injuries, dislocations, muscle strains or spasms, soft tissue injuries, Horner’s Syndrome, diaphragmatic paresis, cervical myelopathy, and costovertebral strains and separations. In rare cases, there may also be risk of stroke with various manipulative procedures, especially the neck or cervical spine. There could also be complications from burns, spread of infections, allergic reactions, skin reactions or other complications from the usage of the adjunct therapy that was listed above as well as diagnostic procedures. Upon signature of this document you give the therapists or practitioner at this facility the right to perform the necessary procedures for treatment and diagnosis, which includes physical examination. During the examination you may be gowned so that the injured area can be properly assessed.

The Dangers and risks of remaining untreated: Remaining untreated allows the possible formation of adhesions and reduces the mobility which sets up a pain reaction further reducing mobility and normal function. Over time, this process may be complicated by chronic degenerative and metabolic changes and prolong or prevent proper treatment, making it more difficult and less effective the longer the condition is postponed. The probability that no/non-treatment will complicate your condition at a later date is very high.

I consent to the performance of the diagnostic and/or therapeutic procedures in addition to, or different from, those mentioned above. I have also been advised of the nature and purpose of the procedures, possible alternatives, and risks/benefits ratio of each. I understand that there are charges for all services rendered, and specific charges will be explained to me upon request.

I have read the office policy of Dr. David W. Lask, D.C. completely. Additionally, the treating physician has also verbally explained this form and satisfactorily answered all my questions. I understand and agree to the above listed terms. I also realize that should I have further concerns, I may contact the Clinic Director at any time.