One of the AAOMPT Fellows I trained took a series of courses from a manual therapist who only teaches spinal manipulation. He states that since the likelihood of serious injury or adverse event is so rare, that informed consent and testing like a premanipulative hold is not necessary. Is it really? I say yes, only if you really want your patient to make a truly informed decision on what is best for them. It's equally important for you to CYA as a practitioner as well. How many patients have you seen that said they have been getting regular cervical manipulations for years? Also, they were never aware of there being an approximately 1 in 10 million chance that something like a VBI or death could occur? It's still safe, the odds are definitely in their favor, with other options such as NSAIDs and spinal surgery having serious complications in the 1 for every 10000 range. It is also more likely you will get into a MVA just by driving in your car daily. Even though studies also show there is no way to predict an adverse event (vertebral artery testing, etc), that shouldn't stop you from doing a premanipulative hold. This will test the patient for any warning signs such as dizziness, diploplia, dysarthria, dysphagia, dizziness, nausea, or anything else they would like to report. If any of those are present, I would retest at another visit. The adverse event normally occurs on the second or third manipulation and not the first. Two to three tests and reminding the patient about possible consequences lightly on the second visit should suffice. I document that the patient gave informed consent verbally in my daily SOAP. Informed consent should be a process and not a piece of paper the patient is most likely not going to read. You may talk some patients out of the treatment they may very well benefit from, but you're doing the right thing for both them and yourself.