Patient Consent Form

CONSENT TO EXAMINATION

I consent to an appropriate physical examination

Consent to Examination

Yes

First Name

Last Name

Date

If you are under 16 years of age, this consent must be agreed by a parent or legal guardian

Consent to Examination by parent or legal guardian

Yes

First Name

Last Name

Date

CONSENT DIAGNOSTIC IMAGING

I have been informed of the need for an appropriate x-ray, MRI or CT scan. I consent to be referred for the relevant procedure.

Consent for Diagnostic Imaging

Yes

First Name

Last Name

Date

If you are under 16 years of age, this consent must be agreed by a parent or legal guardian

Consent for Diagnostic Imaging by parent or legal guardian

Yes

First Name

Last Name

Date

CONSENT TO TREATMENT

I have been advised of, and understood, the possible risks of treatment and had all my questions answered to my satisfaction. I consent to treatment as outlined to me. I also understand that I will have to pay for appointments which I have missed or cancelled with less than 24 hours notice.

Consent to treatment

Yes

First Name

Last Name

Date

If you are under 16 years of age, this consent must be agreed by a parent or legal guardian

Consent to treatment by parent or legal guardian

Yes

First Name

Last Name

Date

CONSENT TO CONTACT YOUR GP

We believe in active communication between healthcare professionals for the good of the patient. To support safe and effective continuum of care I give consent for my Doctor of Chiropractic to share medical information with my GP regarding my case.

Consent to contact your GP

Yes

First Name

Last Name

Date

If you are under 16 years of age, this consent must be agreed by a parent or legal guardian

Consent to contact GP by parent or legal guardian

Yes

Date

ACUPUNCTURE INFORMATION AND CONSENT

I confirm that I have read and understood the below information and I consent to having acupuncture treatment (verbal consent will always be requested before treatment also). I understand that I can refuse this treatment at any time.

Consent to acupuncture treatment

Yes

First Name

Last Name

Date

WHAT IS ACUPUNCTURE?

Acupuncture is a form of therapy in which very fine needles are inserted into the body’s muscles and
fascia. This is a very gentle and safe treatment with serious side effects being incredibly rare (less
than one per 10,000 treatments).

ARE THERE ANY SIDE EFFECTS?

Drowsiness occasionally occurs after treatment with a small number of patients, if this is the case for you, it is best not to drive
Minor bleeding or bruising may occur in 3% of treatments
Pain may occur in about 1% of treatments
Fainting may occur in certain patients, particularly the first treatment. This is very rare.