Patient consent form ENG | Quiropraxia Medellin

Chiropractic, Physiotherapy, Acupuncture Form

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. Reason for consultation?

5. Where is your pain & how long have you had it?

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

7. When was your last chiropractic, physical therapy or chemotherapy?

8. Did you see a doctor or have exams for the pain you have today?

9. What was the doctor or chiropractic diagnosis for your pain?

10. Any past injuries or fractures in the past 10 years. Include approx. dates

I accept the terms and conditions

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