New Patient Form, PowersHealth

Patient Details and Informed Consent *

First

Last

Prefered Name

Address: Number Street Suburb Postcode *

Mobile Phone Number *

Phone Number Other

Email *

Occupation *

Date of Birth *

Who referred you to this clinic/ How did you find out about us

Are you receiving Government Pension or allowances

Pension
Student
DVA
Other

Sports/Hobbies

Who is your General Practioner? *

Are you pregnant?

Are you seeking treatment for a work related injury or Motor Vehicle accident. If yes please provide claim number and insurers details.

Informed Consent to Treatment In this clinic we use a variety of techniques to help you to heal and recover. Kinesiology to assess the meridians’ organs and glands from a natural health perspective. Assessment to check structural and muscular function. However the treatment may involve a combination of herbal/nutritional/diet advice, exercise, as well as in-house treatment that may include chiropractic, acupuncture, guasha, pressure points, gentle electro or laser therapy, meditation and visualisation, ESWT therapy. Some people primarily come in for one modality or the other however the vast majority of people come in for relief of a disorder and want the best ways to overcome that. So selections from of all these techniques are used to enhance your recovery. Most people think of chiropractic as cracking the joints however there are extremely gentle forms that can be used on extremely frail and old osteoporotic patients as well as newborns. This is more a stimulation of the pressure points around the joints to enhance the body’s healing and alignment. As we are fully qualified and recognised in all these disciplines, he needs to attain your informed consent for all of them in order to give you treatment. However at no time will any treatment be given that you would prefer not to have and at all times the patient (or their parent) is in full control. In addition as a health care professional it is important that people who come to see us are informed on results obtained in the past. This helps make an informed decision on their likelihood of success. So in consenting to treatment you are also consenting that your anonymous case (that is reference to your condition and treatment outcomes without in any way referring to you personally) can be used to record the effects of the various treatments that are given and to share that with others. The nature of chiropractic treatment: The Doctor will use his/her hands or a mechanical device in order to move or stimulate your joints. For those patients who desire and in fact need a classical manipulation they may feel a ‘click’ or ‘pop’, such as the noise when a knuckle is cracked, and they may feel the movement of the joint.However very often for those that are more frail then methods such as mobilization and stimulation of the joint are more likely to be used. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used. Possible risks: As with any health care procedure, rare complications are possible following a chiropractic manipulation. Extremely rare complications could theoretically include fractures of bone, muscular strain, ligaments sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. The most recent research on Chiropractic has found there is no causal link to Cerebrovascular accident(CVA) or stroke. It was found that the chance of CVA after a chiropractic treatment is the same as after visiting a General practitioner. What this means is that the CVA is not caused by the treatment administered but is rather occurring prior to treatment and is responsible for the patient presenting for care.This event continues to develop after visit to a practitioner. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. The occasional risk with our treatment is more likely to be some soreness or bruising which is part of the healing process. Probability of Risks: The Risks of complications due to chiropractic treatment have been described as ‘rare’, about as often as complications are seen from the taking of a single aspirin tablet. The probability of adverse reaction due to ancillary procedures is also considered ‘rare’. In spite of the theoretical risks of these extremely safe and natural treatments it is important to put them in context that they are very much lower than having medication side effects or acquiring an infection in a community setting such as a hospital. In addition it is important that problems are treated. In fact by not treating them, there is a greater risk of the disorder deteriorating. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It Power Natural Therapies Centre 149 Lake Road, Port Macquarie NSW 2444 Ph: 6583 9667 Fax: 6583 9650 is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. Acupuncture treatment: In the hands of a well trained professional is also extraordinarily safe. Again in the hands of someone who is incompetent there are risks of creating a pneumothorax or creating a haematoma or to damage an organ or body part where the acupuncture should not be administered. So in signing this form you are just stating that you have had the following unusual risks of your case explained. I have read the explanation above of the chiropractic and acupuncture treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and herby give my full consent to the treatment. Privacy To enable the Practice to continue to deliver and enhance the products and services it provides, the Practice holds personal information about you. We recognise and support your right to full privacy in relation to this information and will continue to handle it with care and in accordance with our professional and legal requirements. The Practice staff will continue to demonstrate integrity and understanding by protecting and keeping secure your personal information. Please take the time to read our Practice’s “Privacy Statement” situated in the reception area. *Your email and address details are taken for many reasons that are for your benefit. It is important to communicate to patients giving them a report of their condition and methods undertaken and to give back-up to the advice given. We may also provide further details of the methods of treatments employed for your benefit. In addition advice is often given in the form of diet, exercise or meditation that goes beyond the treatment time that the patient has paid for. So correspondence on occasions for that purpose is often important. Electronic email is a valuable and simple way of sending information to patients for their benefit. While patients consider themselves to be patients at our clinic we relay in addition information occasionally that pertains to their types of health matters that we believe to be important for our patients in the form of a newsletter and connected health blog. So by giving us your email address and residential address we are able to communicate with you in this manner that is of benefit to you. At no time ever are your details shared with any other person or organization unless we receive your signed request to provide it to them for your own reasons. All your details are treated with respect and any possible contact via these methods is first weighed up for its value to you. INFORMED CONSENT PLEASE TYPE IN YOUR NAME AFTER READING

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