Chiropractic Treatment Consent Form

Captures a patient's health history and informed consent before starting chiropractic treatment.

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Name

First Name

Last Name

Age

Date of Birth

Email

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Please read the following consent carefully before signing.

Emergency Contact Name

First Name

Last Name

Phone Number

Relationship

Do you have any allergies?

Are you currently taking any medications?

Are you pregnant or nursing? (Female only)

Have you been recently hospitalized?

Do you have any current injuries?

Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?

Location of painful areas

Consent

I have read and agree to the terms of this chiropractic treatment consent

Signature of the Client

Sign here

Date Signed

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