Patient Consent Form (Page 2 of 2) in pdf

Patient Consent Form Page 2

GP Letter

It is clinic policy to write to your GP, inform them about your condition and

report your progress.

I do/do not give my consent for the clinic to write to my GP

Signature: ____________________________________________________Date____________

Consent to Examination

I consent to an appropriate physical examination. I have seen the complaints

procedure and understand that it is available to me at any time.

Signature: ____________________________________________________ Date _______________

If you are under 16 years of age, this from should be signed by a parent/legal

guardian.

2nd Visit

Consent to Treatment

I have been given a verbal report of findings at which my diagnosis and

treatment plan were fully explained. I agree to treatment in the following areas:

• Neck

• Upper back

• Lower back

• Other

The risks and benefits of treatment have been explained to me and I have had the

opportunity to ask questions.

I consent to chiropractic treatment.

Signed ____________________________________________________ Date _______________

If you are under 16 years of age, this form should be signed by a parent/legal

guardian.

Patient Consent Form Page 2