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INFORMED CONSENT TO CHIROPRACTIC CARE

This is to confirm that since coming to CBD Health Plus (Chiropractic) – I have completed the entrance questionnaire and am aware that the management used in this centre is specific manipulations, called adjustments.

When performed by a qualified chiropractor, spinal manipulation is an effective and safe method of treatment for many conditions. There is however risks associated with any treatment and I am required to inform you of these even though there has never been a case at this centre. Please read the following carefully and direct any questions you may have to attending chiropractor.

I hereby request and consent to the performance of chiropractic treatment on my self by Dr Louise Mackenzie of Chiropractic BSc, BSc (Chiro) and /or any other chiropractor working in this centre authorized by L Mackenzie.

I have had the opportunity to discuss with L. Mackenzie and/or associate chiropractor the nature and the purpose of chiropractic treatment.

I understand, and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some very slight risks to treatment, including but not limited to, muscle and joint soreness, muscle strains, joint sprains, fractures, disk injuries, strokes and stroke like episodes.

I do not expect the chiropractor to be able to anticipate and explain all-risks and complications and wish to rely on the facts then known is in my best interests. I have read the above and I have had the opportunity to ask questions about its content. I intend this consent form to cover the entire course of treatment for my present condition and for any other future conditions (S) for which I seek treatment.

I understand I can withdraw my consent at any time.

Dated: July 4, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Title*

OCCUPATION
SMS NEXT APPOINTMENT*
No
Yes

MAJOR COMPLAINT
PREVIOUS CHIROPRACTIC CARE*
No
Yes

DATE OF ONSET OF COMPLAINT

HAS THIS OCCURRED BEFORE

HOW OFTEN?

WHAT CAUSED THE COMPLAINT

IS THIS WOKERS' COMPENSATION CLAIM?

CLAIM NO

WHAT TREATMENT HAVE YOU RECEIVED FOR THIS COMPLAINT?

HOW EFFECTIVE WAS THE TREATMENT?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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