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Chiropractic Treatment Consent Form -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Age
Q4

Date of Birth

Date
Q5

Email
Q6

Phone Number

Phone Number
Q7

Address

Street Address
Q8

Address

Street Address Line 2
Q9

Address

City
Q10

Address

State / Province
Q11

Address

Postal / Zip Code
Q12

Emergency Contact Name

First Name
Q13

Emergency Contact Name

Last Name
Q14

Relationship
Q15

Do you have any allergies?
Q16

Are you currently taking any medications?
Q17

Are you pregnant or nursing? (Female only)
Q18

Have you been recently hospitalized?
Q19

Do you have any current injuries?
Q20

Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
Q21

Location of painful areas
Q22

Signature of the Client
Q23

Date Signed

Date