Patient consent form ENG | Quiropraxia Medellin

Chiropractic & Physiotherapy 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

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

“THE PATIENT”, declares that it has been informed that the service / therapy to be provided at IVY Wellness Center & Centro de Quiropraxia is performed by an independent certified practitioner, hereinafter called “THE PROVIDER”.  IVY Wellness Center does not have any type of employment relationship with THE PROVIDER other than renting the space to THE PROVIDER to do their services.  By signing this doc, THE PATIENT releases IVY Wellness Center & Centro de Quiropraxia, its owners, it’s employees & therapists harmless from any lawsuit, claim or liability of any nature from the therapy, including all expenses arising from acts or omissions of THE PROVIDER, which generate damage or harm to the person. The patient also agrees to prevent any third party related to the patient from submitting claims (judicial or extrajudicial) against IVY Wellness Center & Centro de Quiropraxia, it’s owners, employees, or therapists. .  The chiropractic room has a security camara to ensure all services provided by chiropractic are done professionally. This video will automatically be deleted after 30 days. By signing this, THE PATIENT gives consent for video recording of their Chiro, Detox or Acupuncture session.

I accept the terms and conditions

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