Informed Consent

Informed Consent

Chiropractic care is one of the safest forms of health care available. However, health care practitioners are required to inform patients of any possible risk, no matter how rare or slight.

Some people may experience some mild soreness for 24-48 hours after their adjustment. This is a normal sign of change, as may occur after exercise or stretching.

Chiropractic experience consistently demonstrates unexpected improvement in people’s lives. One study indicated that 23% of people experience improvement in some other aspect of their health. Of individuals who experience such improvements:

  • 26% experienced improvements in their respiratory system;
  • 25% in their digestive system;
  • 14% in their circulatory system/heart;
  • 14% in their eyes/vision.

I understand that payment for my program of care is to be made before or after each visit or in the way set out by the payment plan I choose. I also understand that should I have any outstanding invoices on my account including but not limited to declined ACC claims, administration charges, regular appointment fees, outstanding payment plan payments or missed appointment fees, that have not been paid fully within 30 calendar days from the date of issue, Revolution Chiropractic at their own discretion may choose to send my outstanding account to a collection company of their choosing and I will be required to pay any and all collection fees associated with my outstanding account at Revolution Chiropractic.

I understand that I need to give 24-48 hours notice if I need to reschedule my appointment or I may be liable to pay for the appointment fee. It’s important to reschedule your appointment for the same week as this will enable best results for you. (We have a 24 hours cancellation/rescheduling notice policy for our standard appointments and 48 hours on any appointments longer than 30 minutes (family appointments, new patient consultation, examination, new injury). If the required notice is not given a ‘regular visit fee’ may be charged).

I understand that if I sustain a new injury of any sort or I have a private issue to talk about, I will try to call or email RC before my next appointment. This may extend my appointment time to allow for a thorough examination and referral (if needed).

I understand that the adjusting and rehab rooms are open plan therefore if I need special privacy I will need to let RC know in advance and I understand that appointment times may be limited/vary.

I understand that I may need to see the other Chiropractor/s who also practice in RC OR a locum Chiropractor from time to time as my primary Chiropractor may be away or lack availability. This is important for my progress and the smooth running of the office in terms of their appointment scheduling.

I hereby consent to care at Revolution Chiropractic and agree to follow my care plan as it has been designed with my best interests and the results I want in mind.

As a healthcare provider, we are bound by the New Zealand Chiropractic Board Code of Ethics, The Code of Health and Disability Services Consumers Rights, the Health Information Privacy Code 1994 and all other applicable laws. By signing this form, I acknowledge and confirm that

Informed Consent

I have received all the necessary information needed to make an informed choice; give informed consent including but not limited to an explanation regarding my condition and an explanation of the options available including expected risks, side effects, benefits and cost of each option.
The necessary information has been communicated in a form, language or manner that enables me to understand the information provided.

Privacy and Confidentiality

The information I have provided is true and correct.

I authorise the collection, storage, use and disclosure of my personal information in accordance with the privacy act 1993 and health information in accordance with the Health Information Privacy Code 1994.


We are allied health practitioners and are distinct from registered medical doctors.

To the extent permitted by law, we will not be liable for damages of any kind (including without limitation any special, incidental or consequential damages) arising out of or in connection with any advice, treatment, other information or services provided by us to you with your consent.
I have read and fully understand the above statements. All questions regarding the objectives pertaining to my care in this practice have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.