CONSENT TO OSTEOPATHIC TREATMENT

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I hereby consent to receiving osteopathic treatment (or on the patient named below, for whom I am legally responsible) by the osteopath. I understand the importance of accurately disclosing all my medical information and the performance of clinical tests and consent to such.

I understand that results are not guaranteed. I am aware of my right to have a person of my choosing present during physical examination. Should I experience any side effects, I confirm that I will immediately notify my osteopath. I understand that side effects could include mild to moderate discomfort, dizziness, headaches and post treatment discomfort. More severe complications are extremely rare but could include fractures, dislocations, disc herniation or progression of neurological symptoms and stroke. Another treatment that may be utilised is dry needling therapy. Risks associated with dry needling include bruising, bleeding, infection, lung puncture, pain, dizziness and nausea, skin irritation and discomfort. 

The above mentioned side effects may sound conserning but to put it into perspective the risks of severe complications, even using the most conservative estimate, is far (at least 10 times) less than the risk of severe side effects and even death from NSAIDs, one of the most commonly used medications worldwide. 

My failure to notify the practitioner will imply the absence of any side effects. I note my right to withdraw my consent at any time for any specific procedure and/or treatment.

I give my consent for the disclosure of personal information regarding my diagnosis (ICD-10 codes), medical condition, prognosis, treatment compliance and treatment program to the necessary people/institutions for the purpose of referral. 

I enter the premises at my own risk and indemnify the owner of the premises and therapist against any loss or damage of any kind. 

I intend for this consent to apply to my present and future treatments and will apply to all Osteopathic treatments including dry needling unless otherwise withdrawn in person which can be done verbally at any point before or during treatment.