{"id":7911,"date":"2025-11-19T16:50:29","date_gmt":"2025-11-19T16:50:29","guid":{"rendered":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/?page_id=7911"},"modified":"2025-11-19T18:22:11","modified_gmt":"2025-11-19T18:22:11","slug":"chiropractor-consent-form","status":"publish","type":"page","link":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/chiropractor-consent-form\/","title":{"rendered":"Chiropractor Consent Form"},"content":{"rendered":"\n<p><style>\n        .form_addrres ul li {\n            justify-content: flex-end;\n            display: flex;\n            grid-gap: 10px;\n            margin-bottom: 2px;\n        }\n\n        .form_addrres ul li a {\n            color: #525252;\n        }\n\n        .form_icon_box i {\n            color: #f37423;\n        }\n\n        .border_class {\n            background: rgb(83, 83, 83);\n            background: -moz-linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            background: -webkit-linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            background: linear-gradient(90deg, rgba(83, 83, 83, 1) 50%, rgba(243, 116, 35, 1) 50%);\n            filter: progid:DXImageTransform.Microsoft.gradient(startColorstr=\"#535353\", endColorstr=\"#f37423\", GradientType=1);\n            height: 5px;\n        }\n    <\/style><\/p>\n<section id=\"form_section\" class=\"my-3\">\n<div class=\"container\">\n<div class=\"row align-items-center\">\n<div class=\"col-6\">\n<div class=\"form_logo\"><img decoding=\"async\" class=\"img-fluid\" src=\"http:\/\/gorewayphysiotherapy.com\/goreway\/wp-content\/themes\/goreway\/assets\/img\/logo.png\" alt=\"logo\" width=\"270px\" \/><\/div>\n<\/div>\n<div class=\"col-6\">\n<div class=\"form_addrres\">\n <ul>\n                  <li>\n                     <a href=\"tel:+1 (905) 612-8222\">+1 (905) 612-8222<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-phone-flip\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"fax:+1 (905) 612-8752\">+1 (905) 612-8752<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-fax\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"mailto:gorewayphysio@gmail.com\">gorewayphysio@gmail.com<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-envelope\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"https:\/\/gorewayphysiotherapy.com\/\">https:\/\/gorewayphysiotherapy.com\/<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-globe\"><\/i><\/div>\n                  <\/li>\n                  <li>\n                     <a href=\"#\">7330 Goreway Drive, Unit 20\n                     Mississauga, ON L4T 4J2<\/a>\n                     <div class=\"form_icon_box\"><i class=\"fa-solid fa-location-dot\"><\/i><\/div>\n                  <\/li>\n               <\/ul>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/section>\n<section class=\"border_class\"><\/section>\n<div class=\"form_content my-3\">\n<div class=\"container\">\n<div class=\"row\">\n<div class=\"col-12\">\n<h3 class=\"text-center\">CONSENT TO CHIROPRACTIC TREATMENT \u2013 FORM L<\/h3>\n<br \/>\n<p>It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment.<\/p>\n<p>Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise.<\/p>\n<h4>Benefits<\/h4>\n<p>Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery.<\/p>\n<h4>Risks<\/h4>\n<p>The risks associated with chiropractic treatment vary according to each patient\u2019s condition as well as the location and type of treatment.<\/p>\n<p>The risks include:<\/p>\n<p><strong>\u25cf Temporary worsening of symptoms \u2013<\/strong> Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days.&gt;<\/p>\n<p><strong> \u25cf Skin irritation or burn \u2013<\/strong> Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar.<\/p>\n<p><strong>\u25cf Sprain or strain \u2013<\/strong> Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care.<\/p>\n<p><strong>\u25cf Rib fracture \u2013<\/strong> While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention.<\/p>\n<p><strong>\u25cf Injury or aggravation of a disc \u2013<\/strong> Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while. Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. <br \/>The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed.<\/p>\n<p><strong>\u25cf Stroke \u2013<\/strong> \u2013 Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke. Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain. <br \/>Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. <br \/>The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death.<\/p>\n<h4>Alternatives<\/h4>\n<p>Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment.<\/p>\n<h4>Questions or Concerns<\/h4>\n<p>You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor\u2019s attention. If you are not comfortable, you may stop treatment at any time.<\/p>\n<p class=\"text-bold\">Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition.<\/p>\n<p class=\"text-bold\">DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR<\/p>\n<p>I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me.<\/p>\n<\/div>\n<\/div>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7913-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"7913\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7911#wpcf7-f7913-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"7913\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7913-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"text-center\">\n\t<div class=\"form-row text-center\">\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-427\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"inputDate\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-427\" \/><\/span><br \/>\n<label for=\"inputEmail4\"><strong>Name (Please Print) <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-995\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" id=\"inputPatentname\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-995\" \/><\/span><br \/>\n<label for=\"inputPassword4\"><strong>Date <\/strong><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-189\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" id=\"inputPatentname2\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-189\" \/><\/span><br \/>\n<label for=\"inputPatentname2\"><strong>Signature of patient (or legal guardian) <\/strong><br \/>\n<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"text-971\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-971\" \/><\/span><br \/>\n<label for=\"inputPatentname2\"><strong>Signature of Chiropractor <\/strong><br \/>\n<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"form-group col-md-4\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date-976\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-976\" \/><\/span><br \/>\n<label for=\"inputPatentname2\"><strong>Date <\/strong><br \/>\n<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><a href=\"\" target=\"_blank\"><button type=\"button\" class=\"btn btn-danger\">Download PDF<\/button><\/a><br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-success\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>+1 (905) 612-8222 +1 (905) 612-8752 gorewayphysio@gmail.com https:\/\/gorewayphysiotherapy.com\/ 7330 Goreway Drive, Unit 20 Mississauga, ON L4T 4J2 CONSENT TO CHIROPRACTIC TREATMENT \u2013 FORM L It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":4,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7911","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7911","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/comments?post=7911"}],"version-history":[{"count":3,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7911\/revisions"}],"predecessor-version":[{"id":7933,"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/pages\/7911\/revisions\/7933"}],"wp:attachment":[{"href":"https:\/\/convirzon.agency\/Clients\/gorewayphysiotherapy\/wp-json\/wp\/v2\/media?parent=7911"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}