When one seeks chiropractic health care
and is accepted for such care, it is essential for both doctor and
patient to be working towards the same objective.
Chiropractic has only one goal. It is
important that each patient understand both the objective and the
method that will be used to attain it.
Adjustment: An adjustment is the
specific application of forces to facilitate the body's correction
of vertebral subluxation. The chiropractic method of correction is
by specific adjustments of the spine.
Health: A state of optimal physical,
mental, and spiritual well being, not merely the absence of disease
Vertebral Subluxation: A misalignment
of one or more of the 24 vertebra in the spinal column which causes
alteration of nerve function and interference to the transmission of
mental impulses, resulting in a lessening of the body's innate
ability to express its maximum health potential.
Chiropractors do not offer to diagnose
or treat any disease or condition other than vertebral subluxation.
However, if during the course of a chiropractic spinal examination,
non-chiropractic or unusual findings are encountered, you will be
Regardless of what the disease is
called, chiropractors do not offer to treat it. Nor do chiropractors
offer advice regarding treatment prescribed by others. The
chiropractor's only practice objective is to eliminate a major
interference to the expression of the body's innate wisdom. The only
method is specific adjusting to correct vertebral subluxations.
I, (print name)
have read and fully understand the above statements.
All questions regarding the doctor's
objectives pertaining to my care in this office have been answered
to my complete satisfaction.
I therefore accept chiropractic care on
(signature of parent or guardian if patient under 18 years old)