Chiropractic Treatment Consent Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Relationship
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
*
I authorize this chiropractic treatment clinic/center to perform the treatment or necessary procedure for my child.
I acknowledge that I have consulted a chiropractor before undergoing this chiropractic treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my chiropractor.
I acknowledge that this chiropractic treatment has no sexual intent and touching the chiropractort is strictly prohibited.
I release this chiropractic treatment clinic/center for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: