Spark Electric

Informed Consent

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System Template Active physical_therapy

Treatment consent for physical therapy

Fields

Used

Submitted

Patient Name *

Date of Birth *

I consent to physical therapy treatment * Yes

I consent to manual therapy techniques * Yes

I consent to dry needling if recommended Yes

I consent to therapeutic exercise programs * Yes

I acknowledge the risks of treatment have been explained * Yes

Emergency Contact *

Signature *

Signature pad

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