Complementary Medicine Treatment Consent
Please review and complete this form to provide your informed consent for complementary medicine treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any allergies (including medication, food, or environmental)
Please list any current medications or supplements you are taking
Have you previously received complementary medicine treatments?
Yes
No
Not sure
Please describe the reason for your visit or any symptoms you wish to address
Do you have any questions or concerns about the proposed treatment?
Signature
*
Submit Consent
Submit Consent
Should be Empty: