Name *

First Name

Last Name

Review Consent *

I hereby give consent to undergo a chiropractic review, evaluation and/or posture image.

4. Please tick if you are experiencing any of the following:

Increased energy

More balanced

Able to relax more

Feeling stronger

Feeling more alert

Better concentration

Please tick which of the following activities are easier:

Sleeping

Walking

Sitting

Bending/lifting

Driving

Standing

Working

Sports

I am happy for my feedback and pictures to be used in office, on our social media and/or website: *

Yes

No

On-going Consent *

A Chiropractic adjustment is considered to be a safe and effective form of therapy for spinal conditions, i.e. vertebral subluxation. A re-evaluation has been performed. If you have any questions about this, please ask your chiropractor.

I have read the above statement and therefore consent to ongoing spinal adjustive Chiropractic treatment.

Date *

MM

DD

YYYY