Informed Treatment Consent Document
Full Name
*
Date
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Please Select All That Apply
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Spinal manipulative therapy
Palpation
Vital signs
Range of motion testing
Orthopedic testing
Basic neurological testing
Muscle strength testing
Postural analysis testing
Ultrasound
Radiographic studies
Dry needling
Contraindications – Please Inform Us If You Have:
HIV/AIDS or Hepatitis
Unstable Blood Pressure
Active or Recent Infection
Pacemaker or Electrical Implants
Current Use of Blood Thinners
Cancer
Immunosuppressant Medication Use
Diabetes
Needle Phobia
Pregnancy
Name of the Individual
Date Signed
*
Patient name
*
Patient Signature
*
Clear
Signature of Parent or Guardian (if a minor)
Clear
Submit