+Magnolia Wellness Center

2134 Van Ness Ave

San Francisco, CA 94109


Consent To Treat Form

I hereby request and consent to receiving spinal care, including wellness education, in this office by a Chiropractor(s) who provides Network Spinal Analysis (NSA) care, a low force approach which has unique outcomes and clinical results. This practitioner(s) chooses to practice NSA, as (s)he is professionally and personally confident in regard to the safety and effectiveness of this form of care.

This office provides care in accordance with the Council on Chiropractic Practice Guidelines and the Canon of Ethics of the Association of Network Care, and my doctor has been trained in traditional chiropractic care and is certified in the procedures of NSA.

The purpose of this consent form is to help me better understand the nature of the services offered in this office and our mutual responsibilities. This fosters a more effective relationship and avoids misunderstandings regarding expectations. Having well understood expectations is anticipated to promote safety and healing.

NSA does not attempt to manually manipulate spinal fixations structurally (often associated with a snapping or popping sound), nor does it directly treat painful areas of the spine or body. Instead, by enhancing the body’s awareness of itself and specifically the spine, I understand I can develop new strategies for healing, adapting to stress, and experiencing wellness. These strategies promote spontaneous self correction and self regulation of spinal tension patterns and healing.

NSA consists of gentle touch contacts along the neck and back to achieve greater communication between the brain and the body, and new sensory and motor strategies. NSA adopts an approach associated with somatic (body/spinal) awareness training. There is a body of research characterizing NSA care and documenting its unique and spontaneous wellness benefits. I understand I may obtain copies of published research and or abstracts in this office.

I am aware that I will be receiving gentle touch Network Adjustments, also called entrainments. Assessments of my progress will include monitoring of my spine and body awareness, responsiveness to inner rhythms, tension and case patterns. At regular intervals, following commencement of care, re- evaluations will be performed. These will include my personal perception of my wellness and my awareness of my spine and body-mind changes. My chiropractor(s) will report to me the improvement in my spinal and nervous system integrity and my ability to self regulate tension and reorganize my spine.

NSA is advanced through a series of levels of care. Each level of care involves the development of new and unique spontaneous spinal wave motions, other body movements, and oscillations. These waves, which are suggested to be associated with greater spinal stability, re-distribution of energy, and transfer in internal information, are associated with greater wellness, improved quality of life, and increased life enjoyment.

I understand that, in addition to NSA care and wellness education, my practitioner may perform additional examinations and offer health/ spinal care advice that is consistent with my individual needs

Please Read and Sign the Following:

It has been explained to my satisfaction, and I understand the care offered in this office is not a form of, or a replacement for, the diagnosis and/or treatment of any disease, symptom, or malady and I am free to consult or see my medical physician at any time. Instead, NSA is a form of wellness care and self education that empowers my connection with my body-mind and develops new strategies for spinal and nervous system integrity and wellness.

It is common for people receiving NSA care to breathe more deeply and more fully, engaging the spine with their respiration, to spontaneously adapt postures that reduce or redistribute tension, to use stress, and to experience more of their inner life energy.

I understand it is common to experience a wider range of motion and emotion during care. It is common, as care progresses, to find new options in the body and in life which often lead to significant changes. This form of care is not suggested for those individuals who wish to remove a symptom or condition without the occurrence of other fundamental changes in their lives. The care in this office often promotes significant changes in health choices, lifestyle, and experience of the body-mind, emotion and consciousness.

Rather than attempting to simply return me to my previous state minus a symptom, this chiropractor instead chooses to help me achieve new levels of wellness and expression of life expression that I may never have had before. The internal wisdom within my own body is the true agent of healing, empowerment, coordination, inspiration, movement, and joy.

I understand that by their intent, various treatments may actually interfere with the functioning of the nervous system. These include drugs such as pain relievers, muscle relaxes, anti-inflammatory compounds and mood altering medications. These can often delay or prolong the healing process and it is my responsibility to keep my medical physician up to date regarding my changing needs.

I have read, or have had this read to me, this CONSENT TO TREAT FORM, and understand that the care in this office is different from what many consumers may expect from chiropractors practicing manipulative therapy. I agree to receive care. I understand that I am not passive in this process, but I am an active participant in my care and my healing process.