Patient Charts
How do I complete the Informed Consent and Patient Affidavit?
Organization ApprovedSource Verified
Summary
Every patient signs the Informed Consent before any exam, x-ray, or treatment, and every patient except PC patients signs the Patient Affidavit. The CA witnesses both only after watching the patient sign.
- 1Informed Consent to Chiropractic Adjustment, X-Ray and Care must be signed before the doctor can examine, x-ray, or treat the patient.
- 2For female patients, ask “Is there any chance you are pregnant?”, have the patient initial the appropriate line, and note the date of the last menstrual cycle or the reason it does not apply (e.g. “Hysterectomy 2022”).
- 3The patient prints their name, signs, and dates; the CA signs as witness.
- 4For a minor, only the mother, father, or legal guardian may complete the minor section — any other relationship means the minor cannot be treated. A legal guardian requires court-approved guardianship paperwork for the chart.
- 5The doctor reviews and initials the boxed pregnancy area before ordering x-rays for female patients, and draws a line through the box for male patients.
- 6Patient Affidavit: every patient except PC patients signs it, confirming the clinic is not associated with any insurance company, attorney, law firm, or private investigator.
- 7Read each statement aloud; statements two and three are answered Yes and all others No, with the patient circling an answer and initialing next to each — no blanks.
- 8Ask who referred the patient. The referral cannot be an insurance company or representative, but can be a marketer, CWC, attorney, another doctor/facility, a previous patient, or self-referral.
- 9If the patient disagrees with a statement, stop immediately and clarify before they circle an answer; involve the doctor if they remain adamant, and do not treat the patient if the clinic was misrepresented.
- 10The patient signs and dates and the CA signs as witness.
- 11If the Patient Affidavit shows the patient is treating with another doctor, send the affidavit and the Statement of Patient Change of Treating Doctor, on top of the full new patient paperwork, back with the patient to see the doctor; file the completed form on the right side of the chart.
Important
Never correct errors on the Patient Affidavit — start a completely new, clean form.
Citation
CA Manual, Informed Consent; Patient Affidavit; Statement of Patient Change of Treating Doctor, p. Patient Charts · Revised 2/9/26Answers source the CA Manual first; the Medisoft guide is used only where the CA Manual does not cover the task.