Chiropractic Consent Form Free

A chiropractic consent form is a treatment-authorization document with one disclosure that has no equivalent in dentistry: the vertebral artery dissection (VAD) screen and disclosure for cervical HVLA (high-velocity, low-amplitude) thrust adjustments. The free starter version captures the legally-defensible core: the named procedure (HVLA cervical, HVLA thoracic, HVLA lumbar, Activator method, drop-table technique, soft-tissue release, instrument-assisted soft tissue mobilization), the material risks (post-adjustment soreness, exacerbation of existing condition, rib fracture in osteopenic patients, and for cervical specifically the rare-but-documented VAD/stroke risk that case law in WA and MN flagged), the alternatives discussed (medical management, physical therapy, watchful waiting), the contraindications screen (osteoporosis, current anticoagulant use including warfarin/apixaban/clopidogrel, recent cervical trauma, malignancy, vertebrobasilar insufficiency symptoms — dizziness, drop attacks, dysarthria, dysphagia), and the patient's signed acknowledgement. You will customize it. Add your specific technique mix, an X-ray series review acknowledgement if you took or are pulling films, current-medications disclosure, prior-chiro-history and prior-injury fields, and a separate cervical-adjustment-specific consent block triggered when the cervical box is checked. The free template is a defensible skeleton; FCLB recommendations and your state chiropractic licensing board dictate what you must add to make it audit-ready.

Folding cervical consent into the same checkbox as thoracic/lumbar — case law in WA and MN treats cervical HVLA as requiring a heightened, specific disclosure separate from spinal manipulation generally. Skipping the VBI symptom screen (5 D's: dizziness, drop attacks, dysarthria, dysphagia, diplopia, plus ataxia and nausea). Letting the contraindication list omit anticoagulants. Not capturing prior cervical trauma or whiplash history. Forgetting the alternatives-discussed acknowledgement.

Chiropractic consent is governed by HIPAA for the PHI captured and by state chiropractic licensing boards plus the ACA Code of Ethics for the consent itself. The Federation of Chiropractic Licensing Boards (FCLB) explicitly recommends VAD-screening documentation for cervical adjustments — Washington and Minnesota case law (notably the WA Supreme Court ruling in cervical-manipulation malpractice) raised the documentation bar materially. Most state boards require informed consent to include named procedure, material risks, alternatives, and the patient's signature. Retain 7 years; encrypted at rest; e-signatures valid under ESIGN/UETA.

A solo DC running 25-40 patient visits per day typically captures consent at the first visit and refreshes it annually or when the technique mix changes. A multi-DC clinic with 3-5 providers and 80-150 visits per day handles consent volume that demands a structured form, not handwritten notes. Cervical-adjustment volume varies — clinics that do significant upper-cervical work need the VBI screen on every cervical visit; lumbar-only practices need it only when cervical work is added.

A signed PDF capturing patient identification, the named technique, contraindication screen, VBI/VAD screen for cervical work, alternatives-discussed acknowledgement, and patient + provider signatures. Stored encrypted, retrievable for 7-year retention, linkable to the patient chart.

Versus a paid chiro-consent generator: the free version covers the legally-required disclosures (procedure, risks, alternatives, signature) and the FCLB-recommended VBI screen, but stops short of practice-management integrations (auto-attach to chart, ChiroTouch/Genesis sync). Versus a generic consent: the free chiropractic version names chiro-specific risks (VAD, post-adjustment soreness, rib fracture in osteopenic patients) the generic version omits. Versus the paid template tier: the free version is one flow; the template tier branches by technique and patient type.