Patient consent form ENG | Quiropraxia Medellin

Patient History

Full Name

Appnt Date

Age

Type of work you do?

WhatsApp number:

1. Which service desired:

2. Any condition we should be aware of (pregnant, diabetes, hypertension, skin allergies, cancer, tumor, etc.)?

3. Do you have metal screws, metal plates or pacemaker? *people with metal plates, screws or pacemaker cannot do the Ionic Detox program

4. Where is the pain & how long have you had it?

5. What did you do that could have caused the pain you have now?

6. When was your last treatment of chiropractic, physical therapy or chemotherapy?

7. When was your last massage & what type of massage? (sport, deep tissue, relax)

8. List any past injuries or fractures you had in the past 10 years. Include aprox. dates

I accept the terms and conditions

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