niversit Consent and ROF Competency Form cra student Name eee one 04/05/2) Taper Comments Review of findings Tbe + SP? om 76 foo, or” one ese S|. ef 26 Lint oe pl 6/ « ree - Spa 7a fravicen © Solos Pr~ 27K, porreAs pitas =) " 4 T s oot | __ excelent Tat atenpiedo | No oil Do Gooden of Exeter Gemonsated | know Besietr poten | owecge of saath Be tenincaton ad | concepts nd requred Beaton | ousting communkaten and | documentation Consent and ROF competency Marking Form Scanned with CamScanner‘Self-reflection (to be completed by the intern) - what did you learn from this experience, ‘what would you do differently next time. What steps can you implement to ensure the next ‘time you perform this procedure you will doit more professionally (tne oo een Raster pie part + fe pe awe, mele ~ my pla + appre Scanned with CamScannerIniversity Informed Consent for Chiroprac ‘AUSTRALIA 7 Care ‘The alm of the treatment is always te improve the patients health, however, before undergoing 2 treatment a patient should understand the relevant factors in elation tot rl have consulted jentoreen and have received the folowing diagnosis: ‘have been fied pons wien wit te: SOUL te Worley adyustments opt tn ‘understand that my prognosis is (to be circled: poor guarded fair es excellent ‘TU Ahave had the likely effects of having no treatment explained to me. 11. inaminortyofcses the treatment may not be succesful and may be Inthe same poston lam now: 2. "gthough uncommon tetreatmen may mate my conden worse ain the case oftretmentto the pine and extremities legs and arms, temporary Soreness may occur strains and Soran to the muscles, igaments and other sof tissues occur bt are uncommon; rupture to dss between the spinal \vercbra are uncommon butin these cases nerve pan can ersue with atlon of pain nto the arms, unk or legs and nrae instances tiscan cause permanent dsablng pain and weakressin an arm or lee andin very rae instances wel and blader dysfuneion. Another rae events ractre to the ribs bein the case of manipulation or ajstment to the neck there have been reported ational ass of injury to arteries inthe neck These very rare evens but they occur they have Been known to eause stroke sometimes with serious Peer nce mean giad 1D, prsio Macc ee tocar Se eee ees hanuont ‘cf 6. have had the opportunity to ask questions and dscss any concerns have about the effect on my health hat am ‘eancered about in undergoing these procedures, —_7.thave been informed that my anonymised circa fs may be used for research and teaching purposes BS thme ben made oar that ny rations andor reatnetesved tis cay eared fr teching and assessment purpose. A o.tundestand that a srvces/reatment ae provided a student tern under thesupervson of cerfed a practitioner. 10. Ihave had the fees for services and treatments explained to me pae:_3/S fat Patient signature (or egal guardian) Intern signature line Supervisor signature case let CCosciy JO ot a, Rsk of vertebrobasilar stroke and chvopractc cars. Result ofa poputon-based case-control and case-cossove sty. Spine 2008,35:8176.5163 November 13th, 2018 version 1.3 Scanned with CamScanner