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Pediatric History Form 

Child's Current Problem:

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses anddisclosures. I understand that I have the following rights and privileges:- The right to review the notice prior to signing this consent- The right to object to the use of my health information for directory purposes- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, orhealth care operations.

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a"click" or "pop," such noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures, such as hot orcold packs, electric muscle stimulation, or dry hydrotherapy may also be used. Possible Risks: As with any health careprocedures, complications are possible following a chiropractic manipulation. Complications could include bone fractures, muscle strain, ligamentsprain, joint dislocation, or injury to intervertebral discs, nerves, or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury toarteries or the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures couldproduce skin irritations, burns, or minor complications. Probability of risks occurring: The risks of complications due to chiropractic treatmenthave been described as "rare", about as often as complications seen from taking a single aspirin tablet. The risk of cerebrovascular injury or strokehas been estimated at one in one million to one in twenty million and can be even further reduced by screening procedures. The probability ofadverse reaction due to ancillary procedures is also considered "rare". Other treatment options to consider: Over-the-counter analgesics; the risksof these medications include irritation to the stomach, liver, and kidneys, and other side effects in a significant number of cases. Medical care;typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patientdependence in a significant number of cases. Hospitalization; in conjunction with medical care adds risks of adverse reactions to anesthesia, aswell as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows the formation ofadhesions, scar tissue, and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It isquite probable that a delay of treatment will complicate the condition and make further rehabilitation more difficult. Unusual risks: I have had thefollowing unusual risks of my case explained to me. I have read the explanation above of chiropractic treatment. I have had the opportunity tohave any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided toundergo the recommended treatment, and hereby give my full consent to treatment.

CONSENT TO TREATMENT OF A MINOR CHILD: I hereby authorize Dr. Tori Ritchie and/or Dr. Sandra Buffkin and whomever she may designate asassistants to administer chiropractic care as deemed necessary to my child.