New Patient – Chiropractic Child 0-5

New Patient – Chiropractic Child 0-5

Welcome to Thrive Health Co. If you are a new patient to our clinic for Chiropractic Care, please complete the online form below and submit.

For your Chiropractor to determine the appropriate care for your child a thorough examination must be completed.
By signing this form you grant permission for the Chiropractor to:
* Gather all appropriate information about your child, his/her gestation, birth and health history
* Perform a full examination with chiropractic, orthopaedic and neurological tests to assess his/her current level of health
and function
* Provide a chiropractic care plan at the report visit including chiropractic adjustments and adjunctive care where

The Health & Safety of Your Child Comes First
By signing below I understand and agree with the following statements:
* The information provided is accurate and all inclusive
* With any health care modality there may be some risks associated with care provided. I have been informed and I
understand what those risks may be.

* I have had the opportunity to discuss with my child’s Chiropractor the nature of the care recommended, the risks
associated with the recommended care and the likely outcome
* I understand that the likely outcome of the care is not guaranteed
* I do not expect my child’s Chiropractor to anticipate and explain all risks and complications but rely upon the
Chiropractor to exercise judgment during the course of the care based upon the facts known at the time
* I have read the above and been given the opportunity to ask questions about this document and the examination
process, procedures and following report in detail
* I will notify the Chiropractor of any major falls, illnesses or other instances where my child’s health has been
compromised at any point during care
* I acknowledge the Chiropractor will use specific chiropractic techniques suitable for my child’s age and body type to
ensure safe and gentle care is provided

Current Research About Chiropractic Care For Kids
As with any health care physical examination and/or care provided support there is a risk (however small) of a condition changing or an adverse outcome from the treatment. Latest research (2014/2015) analysis showed no serious adverse events have been reported to be associated to care provided by a chiropractor since 1992, and no deaths from paediatric chiropractic care has been reported in the literature. Research (2009) conducted by the International Chiropractic Pediatric Association demonstrated chiropractic care is very safe for kids.
The research of 5,438 chiropractic visits, 577 children, parents indicated;
* Only two children ( <1%) experienced minor discomfort after an adjustment, which readily resolved with continued
chiropractic care
* The research showed both parents and doctors indicated a high rate of improvement with respect to the children’s
presenting complaints.
* Parents also reported better sleeping patterns, improvements in behaviour and, improved immune system function while
under chiropractic care.
JMPT 2014; (Published Online October 29 2014:1-14) Adverse Events Due to Chiropractic and Other Manual Therapies for Infants and Children: A Review of the
Literature. Todd et al. Explore (NY). 2009 Sep-Oct;5(5):290-5. The safety and effectiveness of pediatric chiropractic: a survey of chiropractors and parents in a practicebased
research network. Alcantara J, Ohm J, Kunz D.
JMPT 2015 Nov-Dec;38(9):699-712 Adverse Events to Chiropractic and Other Manual Therapies for Infants and Children: A review of the Literature. Todd AJ,
Carroll MT, Robinson A, Mitchell EK.


Thrive Health Co provides allocated appointment times to ensure the provision of essential and high quality care at all times. Therefore, for non-attendance, cancellations or change of appointment day without notice of at least 12 business hours, you will incur a cancellation fee of the 50% of our standard price. Any cancellations provided at least 12 business hours prior to your appointment time, will be at no charge.

If we receive advanced notice that you are unable to attend, other clients who may require an appointment with a therapist may be able to be seen in your time slot. Please be considerate of other people who may be requiring an appointment and are unable to get in with a therapist in a timely manner or at a time that suits them.

I accept financial responsibility for my consultations and treatment. Fees are due at the time of visit unless arranged, and agreed upon, in advance. Unauthorised late payments will attract administration fees, details of which are available on request.

Referrals Appreciated - as we are a family owned and operated practice – the majority of our patients come via the kind referrals from our current patients – just like you – this reduces our need to waste money on expensive advertising and concentrate on what we do best – helping as many people as possible. We thank you in advance for your kind referrals and support.

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