Preamble
This Patient Informed Consent Agreement ("Agreement") is entered into between WhiteRock Wellness LTD ("the Clinic", "we", "us"), a registered healthcare provider operating from No. 3 Ayobaba Tunde Crescent, Oniru, Lagos, Nigeria, and the undersigned patient ("the Patient", "you"). By submitting this form, you affirm that you have read, understood, and voluntarily agree to all terms contained herein. This Agreement constitutes a legally binding document and shall govern the entirety of your clinical relationship with WhiteRock Wellness LTD.
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, a chiropractor trained at a leading Chinese chiropractic institution, combining Eastern precision with Western evidence-based medicine. Our mission is to identify and eliminate the root cause of pain — not merely suppress symptoms — to restore patients to full function and optimal health.
WhiteRock Wellness operates on the principle of root-cause correction. We treat the source of your condition, not just the symptoms. This approach requires honesty from patients about their full medical history and compliance with the prescribed treatment plan for best outcomes.
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 (subluxations), relieve nerve compression, restore range of motion, and promote the body's natural healing capacity. The techniques employed at WhiteRock Wellness may include spinal high-velocity low-amplitude (HVLA) thrust adjustments, spinal mobilisation, decompression techniques, soft tissue manipulation, therapeutic massage, and rehabilitative exercises.
IMPORTANT — PLEASE READ: Chiropractic adjustment and bone-setting procedures are clinical interventions that involve physical manipulation of your body. It is entirely normal — and clinically expected — 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 to the correction of long-standing structural dysfunction and are not indicative of injury. Most patients experience significant and lasting relief following the initial recovery period of 24–72 hours. The discomfort is temporary; the relief is the goal.
You acknowledge that you have been fully informed of the physical nature of chiropractic treatment and that you voluntarily consent to receive such treatment, understanding that physical discomfort during and after the procedure is an inherent and expected component of the therapeutic process and does not constitute negligence, malpractice, or grounds for complaint or refund.
Known Risks & Contraindications
As with all clinical interventions, chiropractic care carries a small but documented risk profile. By proceeding, you acknowledge awareness of the following potential — though rare — adverse effects:
(a) Temporary soreness, aching, or stiffness in the treated area lasting 24–72 hours after adjustment;
(b) Temporary increase in pain intensity as the musculoskeletal system readjusts;
(c) In extremely rare cases (<1 in 5.85 million cervical adjustments), vertebrobasilar artery injury — a risk comparable to spontaneous occurrence in the general population;
(d) Minor bruising at points of soft tissue treatment;
(e) Temporary nerve sensitivity or numbness in adjacent areas.
You confirm that you have disclosed all relevant medical history, current medications, prior surgeries, and existing conditions that may affect treatment safety. 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 and discontinue treatment at any time during a session by clearly communicating this to your treating practitioner. However, you acknowledge that partial or incomplete treatment courses may reduce the efficacy of care and are not grounds for a fee refund. WhiteRock Wellness reserves the right to decline or discontinue treatment if, in the clinical judgment of the practitioner, continuation would be unsafe or contraindicated.
Medical History Accuracy
You warrant that all medical information provided in this form and during clinical consultations is accurate, complete, and truthful to the best of your knowledge. You understand that withholding, misrepresenting, or omitting material medical information constitutes a breach of this Agreement and may result in harm, for which WhiteRock Wellness LTD and its practitioners cannot be held responsible. You agree to promptly notify your practitioner of any changes to your health status, medications, or circumstances that may be relevant to your care.
Treatment Plan & Clinical Discretion
WhiteRock Wellness LTD retains full clinical discretion in determining the appropriate treatment modalities, frequency, and duration of care based on the patient's presenting condition. Recommendations provided by the clinical team are based on professional assessment and international chiropractic standards. The number of sessions required varies by individual condition, severity, duration, and patient compliance, and the Clinic makes no guarantee of specific outcomes within a prescribed timeframe, though the clinical team will always endeavour to achieve the best possible result.
Confidentiality & Data Protection
All personal and medical information collected through this form and during your treatment at WhiteRock Wellness LTD is held in strict confidence. Your data will be used solely for the purposes of clinical care, treatment planning, and operational records of this clinic. We do not share, sell, or disclose your information to third parties without your explicit written consent, except where required by Nigerian law or in a medical emergency requiring disclosure to emergency services. By submitting this form, you consent to WhiteRock Wellness retaining your records for a minimum of seven (7) years in accordance with standard medical practice obligations.
Payment Terms
All consultation and treatment fees are due at the time of service unless alternative arrangements have been expressly agreed in writing by clinic management. The initial consultation fee is ₦20,000 per session. Subsequent session fees may vary depending on the treatment modality and duration. 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 policy applies without exception to:
(i) Consultation fees paid prior to or at the time of assessment;
(ii) Session fees paid for treatment sessions commenced or partially completed;
(iii) Package or prepaid session fees, regardless of how many sessions have been attended;
(iv) Fees paid where the patient voluntarily withdraws from treatment mid-session or mid-course;
(v) Fees paid where the patient experiences expected discomfort or temporary pain during or following adjustment — as explicitly disclosed in this Agreement.
The rationale for this policy is as follows: WhiteRock Wellness LTD commits significant clinical time, expertise, practitioner preparation, facility resources, and administrative effort to each patient encounter from the point of booking confirmation. These resources are expended regardless of whether the patient ultimately finds the session comfortable. Post-treatment discomfort is a clinically normal and expected outcome of chiropractic and bone-setting procedures and does not constitute a service failure.
In the event of a verified administrative error or a genuine contraindicated treatment that could not have been reasonably identified without the patient's disclosed history, the Clinic reserves the discretion — but not the obligation — to offer a session credit. 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. This policy exists to respect the time of our clinical staff and other patients who may have required that appointment slot.
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 of this Agreement 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 of WhiteRock Wellness LTD;
(f) You consent to receive chiropractic, physiotherapy, and/or allied wellness treatment from WhiteRock Wellness LTD and its clinical team.