Chiropractic consent form template
A chiropractic informed consent form explains what an adjustment is, what else treatment might include, and what the risks are, in words a new patient can follow. It records that they agreed after hearing it. Read this one below, then open it in SignMaster so new patients can read and sign it on their phone before the first visit, instead of on a clipboard in the waiting room.
Updated November 5, 2026 · 3 min read
The contract
Gray blanks are yours to fill in before you send. Each signer fills in the blanks in their color.
- You, before sending
- Patient
- Chiropractor
Chiropractic Informed Consent to Treatment
Patient name: Patient name Date of birth: Date of birth
This form explains the care offered at Clinic name (the "Clinic") by Chiropractor and license and the Clinic's other doctors and staff, so the patient can decide whether to go ahead. Please read it, ask about anything unclear, and sign only when you're comfortable.
1. What care may involve
Care starts with a history and examination, and may include imaging such as X-rays if they're needed, at the Clinic or by referral. Treatment may include:
- Adjustments (manipulation) of the spine or other joints: a quick, controlled push that may make a popping sound.
- Mobilization, stretching and soft-tissue work on muscles.
- Instrument-assisted adjustments, a slower and gentler option.
- Heat, ice, electrical muscle stimulation, ultrasound or other therapies.
- Exercises and advice on posture and activity to continue at home.
2. Expected benefits
Chiropractic care aims to reduce pain and improve movement and function. Results differ from person to person, and the Clinic cannot promise a particular result or how many visits it will take. The doctor will review progress with the patient and change or stop the plan if it isn't helping.
3. Risks
- Common: soreness, stiffness, a headache or tiredness for a day or two after treatment.
- Uncommon: muscle strain or sprain, skin irritation from electrodes, or a burn from a heat or ice pack.
- Rare: a rib or other bone fracture, more likely with weakened bones, or a worsening disc injury.
- Very rare: neck manipulation has been linked to a tear in an artery in the neck that can lead to a stroke. Researchers still debate whether manipulation causes these tears, or whether some patients already have a tear starting when they seek care for neck pain or headache. Tell the doctor at once about sudden severe headache, dizziness, double vision, trouble speaking or numbness.
4. Other options
Other choices include rest, home exercise, over-the-counter or prescription medicine, physical therapy, injections, surgery, or no treatment. The patient may discuss these with the Clinic or with their medical doctor before deciding.
5. Your health information
Some conditions change how care should be given. Please list any of these that apply: osteoporosis, cancer, a recent fracture or surgery, blood-thinning medicine, an earlier stroke or blood vessel problem, inflammatory arthritis, a joint replacement or spinal implant, or a pacemaker. Health conditions
I am pregnant or may be pregnant. Imaging won't be taken without discussing it first, and treatment will be adapted.
6. Your right to choose
The patient may refuse any part of care, ask for a different technique, or stop at any time, and will not be pressured to continue. Treatments the patient does not want, if any: Treatments declined.
7. Patients under 18
A patient under 18 needs a parent or legal guardian to sign this form, and a parent or guardian will be present at the first visit and whenever the Clinic asks. Parent or guardian name, if signing for a minor: Parent or guardian name.
8. Fees and records
Fees and insurance billing are explained in the Clinic's separate financial policy. The Clinic keeps this form and the patient's treatment records confidential and shares them only with the patient's permission or as the law requires.
9. How long this consent lasts
This consent covers the patient's care at the Clinic until the patient withdraws it in writing. The doctor will explain any treatment not listed above before using it, and will ask the patient to update their health information when it changes.
Contact details
Patient phone: Patient phone Email: Patient email Emergency contact: Emergency contact
I have read this form, including the risks in section 3, my questions have been answered, and I consent to chiropractic examination and treatment.
Patient, or parent or guardian of a minor
Chiropractor
Opens it in SignMaster as a template you can edit and send.
A starting point, not legal advice. Have a lawyer review it for your state and situation.
On this page
Why chiropractors use written consent
Informed consent is a conversation: the doctor explains the proposed care, its benefits and risks and the alternatives, and the patient decides. The written form backs that conversation up. It shows the patient was told about the common after-effects, like soreness for a day or two, and about the rare serious ones, and that they had the chance to say no to any technique.
Have every new patient sign before the first adjustment, and revisit it when you add a treatment the form doesn't describe or when their health changes in a way that matters, such as a new osteoporosis diagnosis or a pregnancy.
What the template covers
- What care may involve: history and exam, imaging when needed, adjustments, mobilization, soft-tissue work, instrument adjustments, therapies and home exercise.
- Benefits: less pain and better movement, with no promise of a result or a visit count.
- Risks in plain words: common soreness, uncommon strains and burns, rare fractures and disc injury, and the very rare neck artery tear, explained fairly.
- Warning signs: the symptoms that mean tell the doctor at once.
- Alternatives, from rest and medicine to physical therapy and surgery.
- Health conditions that change treatment, and a pregnancy box.
- The right to refuse, with a blank for techniques the patient doesn't want.
- Minors, fees, records and how long consent lasts.
Mistakes to avoid
- Leaving out the stroke question. Patients search for it; a form that says nothing reads as hiding it. State the risk and the open research question plainly.
- Collecting consent once and never again. If a patient's care moves to a new technique or their health changes, have them sign a fresh copy.
- Making refusal hard. A blank where the patient can write "no neck adjustments" respects their choice and tells every doctor in the clinic.
- Letting a teenager sign alone. A parent or guardian signs for a minor and should be at the first visit.
Check your board's rules and your privacy duties
Informed consent requirements for chiropractors come from state law and licensing boards, so compare the risk section with your board's rules and your malpractice carrier's guidance. Clinics that bill insurance are usually HIPAA covered entities; SignMaster doesn't claim HIPAA compliance, so ask your compliance adviser before you collect health history through it.
How to send it with SignMaster
- 1
Open the template
Choose Use this template. It's set up with the patient signing first and the chiropractor second.
- 2
Add the clinic's details
Fill in the gray blanks with your clinic name and the doctor's name and license number. If you don't offer a listed therapy, strike it through with the editor's Markup tools.
- 3
Send it with the new-patient booking
Enter the patient's name and email, or share a public signing link on your new-patient page. The patient fills in the blue blanks, their conditions, declined treatments and contacts, and signs.
- 4
Or sign at the front desk
For a patient who arrives without it, hand them the clinic iPad with in-person signing. The certificate records that they signed in person.
- 5
Doctor countersigns after the talk
Sign after the consultation, once you've answered the patient's questions. Both of you get the signed PDF by email.
For parents bringing a child
When the patient is under 18, send the envelope to the parent's email instead of the child's. The parent fills in their own name in section 7 and signs for their child. For both parents, add another signer role and signature field in the template editor. See get a parent's signature for a minor.
Questions? Answers.
Do chiropractors need written informed consent?
Informed consent itself is a legal and ethical duty; whether it must be written depends on your state and board, and malpractice carriers generally recommend it. A signed form is the easiest way to show the conversation happened.
Should the form mention stroke?
Most careful consent forms do. The link between neck manipulation and artery tears is rare and debated, but patients ask about it, and a fair explanation builds trust.
Can patients sign on their phone before the first visit?
Yes. They open the link from your email or website, read the form, fill in their health details and sign, with no account or app.
Is an e-signed consent form legally valid?
Generally, yes: federal and state e-signature laws treat it like ink for most records. See can you e-sign a medical consent form.