Preamble
This Patient Informed Consent Agreement ("Agreement") is entered into between WhiteRock Wellness LTD ("the Clinic") and the undersigned patient ("you"). By submitting this form, you affirm that you have read, understood, and voluntarily agree to all terms contained herein.
About WhiteRock Wellness
WhiteRock Wellness LTD is a specialist musculoskeletal clinic offering chiropractic care, physiotherapy, therapeutic massage, and allied wellness services. Our clinical team is led by Dr. Paul Johnson Chima. Our mission is to identify and eliminate the root cause of pain — not merely suppress symptoms.
WhiteRock Wellness operates on the principle of root-cause correction. We treat the source of your condition, not just the symptoms.
Nature of Chiropractic Treatment & Expected Sensations
Chiropractic care involves the manual manipulation and adjustment of the spine, joints, and associated soft tissues to correct misalignments, relieve nerve compression, restore range of motion, and promote the body's natural healing capacity.
IMPORTANT — PLEASE READ: Chiropractic adjustment and bone-setting procedures involve physical manipulation of your body. It is entirely normal to experience temporary discomfort, soreness, stiffness, clicking or popping sounds, and brief intensification of existing pain during and immediately following treatment. These sensations are a natural physiological response and are not indicative of injury. Most patients experience significant and lasting relief following the initial recovery period of 24–72 hours.
You acknowledge that you have been fully informed of the physical nature of chiropractic treatment and that you voluntarily consent to receive such treatment.
Known Risks & Contraindications
As with all clinical interventions, chiropractic care carries a small but documented risk profile. Known risks include temporary soreness lasting 24–72 hours, temporary increase in pain intensity, minor bruising at points of soft tissue treatment, and temporary nerve sensitivity. You confirm that you have disclosed all relevant medical history. WhiteRock Wellness cannot be held liable for adverse outcomes arising from undisclosed medical information.
Voluntary Consent & Right to Withdraw
Your consent to treatment is entirely voluntary. You have the right to withdraw consent at any time during a session by clearly communicating this to your treating practitioner. However, partial or incomplete treatment courses are not grounds for a fee refund.
Medical History Accuracy
You warrant that all medical information provided is accurate, complete, and truthful to the best of your knowledge. Withholding or misrepresenting material medical information is a breach of this Agreement.
Confidentiality & Data Protection
All personal and medical information is held in strict confidence. Your data is used solely for clinical care and operational records. We do not share your information with third parties without your explicit consent, except where required by Nigerian law or in a medical emergency. By submitting this form, you consent to WhiteRock Wellness retaining your records for a minimum of seven (7) years. To request a copy of your records, or to ask a question about how your data is handled, contact the clinic on +234 816 284 7976.
Payment Terms
All consultation and treatment fees are due at the time of service. The initial consultation fee is ₦20,000 per session. Subsequent session fees may vary depending on the treatment modality. Payment may be made by cash or bank transfer. WhiteRock Wellness does not currently accept HMO coverage.
⛔ STRICT NO-REFUND POLICY
NO REFUND POLICY — PLEASE READ CAREFULLY BEFORE PROCEEDING.
All fees paid to WhiteRock Wellness LTD are strictly non-refundable. This applies without exception to consultation fees, session fees paid for treatment commenced or partially completed, package or prepaid session fees, and fees paid where the patient experiences expected discomfort or temporary pain during or following adjustment — as explicitly disclosed in this Agreement.
Post-treatment discomfort is a clinically normal and expected outcome of chiropractic and bone-setting procedures and does not constitute a service failure. Cash refunds will not be issued under any circumstances.
Appointment Cancellation Policy
We respectfully request a minimum of 24 hours notice for appointment cancellations or rescheduling. Late cancellations (within 24 hours) or no-shows may result in forfeiture of the session fee or deposit.
Declaration
By electronically signing this Agreement, you declare that: (a) you are 18 years of age or older, or are the parent/legal guardian of the patient named herein; (b) you have read, understood, and voluntarily agree to all terms without coercion; (c) all information provided is accurate and complete to the best of your knowledge; (d) you understand and accept the nature of chiropractic treatment including the likelihood of physical discomfort; (e) you understand and accept the strict no-refund policy; (f) you consent to receive chiropractic, physiotherapy, and allied wellness treatment from WhiteRock Wellness LTD and its clinical team.