Colacurcio Wellness - Caldwell NJ 973-228-2481

Consent to Treat Form


Patient's Name:  

I have been informed of the nature of my disorder(s) and of the nature and purpose of Chiropractic care, physical therapy by chiropractor, massage therapy, and or personal training as procedures proposed as treatment. I have also been informed of the possible consequences and risks inherent in such treatment. The availability of alternative treatment options has been explained to me. I have also been advised of the possible consequences if I decide not to receive care. I understand that there is no guarantee or warranty for any specific cure or result.

I HAVE READ THE ABOVE PARAGRAPH AND I UNDERSTAND THE INFORMATION PROVIDED. THIS INFORMATION HAS BEEN EXPLAINED TO ME, AND ALL QUESTIONS WHICH I HAVE ASKED HAVE BEEN ANSWERED TO MY SATISFACTION.

I THEREFORE AUTHORIZE Steve Colacurcio DC, Colacurcio Wellness LLC, Evolution Health & Fitness, and their Independent Contractors TO PROCEED WITH chiropractic, physical therapy by chiropractor, massage therapy, and or personal training for treatment.

 


When the patient is a minor or unable to consent:

Patient's legally authorized signer please complete the below form. 

Patient's Age:
Patient's Name:
Authorized Person's Name:
Relationship:
 
Patient or Authorized Person's signature:

Leave this empty:

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Signature Certificate
Document name: Consent to Treat Form
lock iconUnique Document ID: f95ddf3b2ddf8299590cc0c6638f10866196b76d
Timestamp Audit
September 13, 2022 1:58 pm ESTConsent to Treat Form Uploaded by Steve Colacurcio - scolacurcio@icloud.com IP 173.70.19.34